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Questions 148

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Question 1 of 5

Upon admission to the hospital, a client reports having 'the worst headache I've ever had.' The nurse should give the highest priority to:

Correct Answer: C

Rationale: A sudden, severe headache may indicate a serious condition like subarachnoid hemorrhage. Neuro checks are the priority to assess for neurological changes.

Question 2 of 5

The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:

Correct Answer: A

Rationale: Applying antithrombic stockings before rising prevents venous pooling, maximizing their effectiveness in improving circulation.

Question 3 of 5

The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?

Correct Answer: C

Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.

Question 4 of 5

A 68-year-old client states he decided not to take the herpes zoster (shingles) immunization because his friend had the immunization and still developed shingles. Which of the following information should the nurse include when discussing this issue with the client? Select all that apply.

Correct Answer: B,C,D

Rationale: The shingles vaccine reduces severity (
B), postherpetic syndrome risk (
C), and shingles incidence by about 50% (
D). It doesn't eliminate risk (
A), and dismissing friends' advice (E) is inappropriate.

Question 5 of 5

A client's blood pressure is 132/84. What is the mean arterial pressure?

Correct Answer: C

Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg.
Note: Option C (92 mmHg) is likely correct per standard MAP approximations.

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