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Questions 149

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Question 1 of 5

Which of the following roommates would be most suitable for the client with myasthenia gravis?

Correct Answer: A

Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.

Question 2 of 5

A pregnant client, age 32, asks the nurse why her doctor has recommended a serum alpha fetoprotein. The nurse should explain that the doctor has recommended the test:

Correct Answer: D

Rationale: Serum alpha fetoprotein screening detects neural tube defects, such as spina bifida.

Question 3 of 5

The nurse caring for a client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 150/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?

Correct Answer: B

Rationale: Bone metastasis often causes hypercalcemia (calcium 13 mg/dL is elevated), leading to confusion and hypertension. The other values are normal or unrelated.

Question 4 of 5

The client is newly diagnosed with juvenile onset diabetes. Which of the following nursing diagnoses is a priority?

Correct Answer: C

Rationale: Knowledge deficit is a priority, as education on managing juvenile diabetes is critical for long-term health and compliance.

Question 5 of 5

An older adult has become very confused after surgery for repair of a hip fracture. The client has repeatedly tried to climb over the bedrails and the nurse is considering placing the client in a Posey vest that is secured to the bed. Which of the following must the nurse consider when applying restraints to a client? Select all that apply.

Correct Answer: A,C,D

Rationale: Alternatives (
A), reassessment every 2 hours (
C), and a written policy (
D) are required for restraints. Confused clients aren't always safer (
B), most restrictive (E) is incorrect, and an order is needed (F).

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