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Questions 158

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Extract:


Question 1 of 5

Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?

Correct Answer: B

Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.

Question 2 of 5

Discharge teaching was effective if the parents of a child with atopic dermatitis could state the importance of:

Correct Answer: D

Rationale: Maintaining a low-humidified environment. Avoiding furry, soft stuffed animals for play, which may increase symptoms of allergy. Avoiding showering, which irritates the dermatitis, and encouraging bathing 4 times a day in colloid bath for temporary relief. Wrapping hands in soft cotton gloves to prevent skin damage during scratching.

Question 3 of 5

An 80-year-old widow is living with her son and daughter-in-law. The home health nurse has been making weekly visits to draw blood for a prothrombin time test. The client is taking 5 mg of coumadin per day. She appears more debilitated, and bruises are noted on her face. Elder abuse is suspected. Which of the following are signs of persons who are at risk for abusing an elderly person?

Correct Answer: A

Rationale: This answer is correct. Two risk factors are identified in this answer. This answer is incorrect. Persons at risk tend to lack communication skills and effective coping patterns. This answer is incorrect. Persons at risk are usually family members or those reluctant to provide care. This answer is incorrect. This individual has a vested interest in providing care.

Question 4 of 5

A client with increased intracranial pressure is receiving Osmitrol (Mannitol) and Furosemide (Lasix). The nurse recognizes that these two drugs are given to reverse which effect?

Correct Answer: C

Rationale: Mannitol and Furosemide reduce cellular edema by promoting diuresis and osmotic fluid shifts, lowering ICP. Energy failure (
A), calcium (
B), and glutamate (
D) are not directly targeted.

Question 5 of 5

The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:

Correct Answer: B

Rationale: A pH of 7.47 (alkaline) with low PCO2 (28) indicates respiratory alkalosis, likely from hyperventilation due to brain injury. Normal HCO3 rules out metabolic causes.

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