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Questions 149

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Extract:


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 assessing a 6-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?

Correct Answer: A

Rationale: Drooling of bright red secretions indicates active bleeding, a critical sign of post-tonsillectomy hemorrhage requiring immediate attention.

Question 3 of 5

The nurse is preparing to discharge a client following a trabeculoplasty for the treatment of glaucoma. The nurse should instruct the client to:

Correct Answer: D

Rationale: Eye protection prevents injury and supports healing post-trabeculoplasty.

Question 4 of 5

The nurse is caring for a client with Crohn's disease. How should the nurse educate the client regarding nutrition and hydration?

Correct Answer: C

Rationale: High-calorie, low-fiber, high-protein, and high-vitamin foods support nutrition in Crohn’s disease while minimizing irritation to the inflamed bowel.

Question 5 of 5

A newborn diagnosed with bilateral choanal atresia is scheduled for surgery soon after delivery. The nurse recognizes the immediate need for surgery because the newborn:

Correct Answer: D

Rationale: Bilateral choanal atresia blocks the nasal passages, preventing nasal breathing, which is critical for newborns who are obligate nose breathers.

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