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Questions 164

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Question 1 of 5

The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:

Correct Answer: B

Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.

Question 2 of 5

The nurse is talking to a client with a newly diagnosed seizure disorder who has a prescription for levetiracetam. Which of the following statements by the client would require follow-up?

Correct Answer: A

Rationale: Driving restrictions for seizure disorders typically last 6-12 months seizure-free, not 2 weeks, posing a safety risk. Reporting rashes and anxiety are correct due to potential side effects of levetiracetam.

Question 3 of 5

The nurse is caring for a client who has developed cardiac tamponade. Which finding would the nurse anticipate?

Correct Answer: C

Rationale: Distended neck veins. Cardiac tamponade causes venous congestion, leading to distended neck veins.

Question 4 of 5

What nursing action is essential when oxygen is ordered for a client who is living at home?

Correct Answer: A

Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.

Question 5 of 5

The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?

Correct Answer: C

Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.

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