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Questions 149

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Question 1 of 5

While performing a neurological assessment on a client with a closed head injury, the nurse notes a positive Babinski reflex. The nurse should:

Correct Answer: D

Rationale: A positive Babinski reflex in an adult with a head injury suggests neurological damage, warranting immediate physician notification.

Question 2 of 5

The nurse is caring for a client who was admitted for chest pain. The client is oriented to person and place, but is often confused about the month of the year or what season it is. A family member tells the nurse, 'I'd like for you to sign as a witness on my mother's living will, in case something happens to her and we need to make health care decisions for her.' Which is the best response by the nurse?

Correct Answer: C

Rationale: The client’s confusion raises concerns about her capacity to understand the living will, which must be addressed before witnessing to ensure validity.

Question 3 of 5

The home health nurse is planning for the day's visits. Which client should be seen first?

Correct Answer: C

Rationale: The client with a decubitus ulcer is at risk for infection and complications, making them the priority for assessment.

Question 4 of 5

An elderly client is diagnosed with interstitial cystitis. Which finding differentiates interstitial cystitis from other forms of cystitis?

Correct Answer: B

Rationale: Interstitial cystitis is characterized by chronic pelvic pain and urinary symptoms with sterile urine, as it is not caused by bacterial infection, unlike other forms of cystitis.

Question 5 of 5

A client with end stage renal disease is being managed with peritoneal dialysis. If the dialysate return is slowed the nurse should tell the client to:

Correct Answer: D

Rationale: Changing position or turning side to side can help dislodge obstructions or reposition the catheter, improving dialysate flow.

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