The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?

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Question 1 of 5

The nurse is providing post-operative care to the craniotomy client. Diabetes insipidus is suspected when the client's urine output suddenly increases significantly. Which action takes highest priority?

Correct Answer: C

Rationale: The correct answer is to check a blood pressure. Diabetes insipidus can lead to dehydration and potential hypovolemic shock due to excessive urine output. Monitoring blood pressure is crucial to assess the client's circulatory status and detect signs of shock early. Checking the blood pressure will provide essential information on perfusion, which is vital in this situation. Continuing to monitor urine output, checking a pulse, or assessing the level of consciousness are important but not as high a priority as evaluating the blood pressure in a potentially critical situation like suspected diabetes insipidus.

Question 2 of 5

A patient has been diagnosed with fibromyalgia and COPD. Which of the following tasks should the nurse delegate to a nursing assistant?

Correct Answer: A

Rationale: The correct answer is to delegate the task of transferring the patient to the shower to a nursing assistant. Nursing assistants are trained to assist with transfers safely, making this task appropriate for delegation. Ambulating the patient for the first time involves assessing the patient's mobility and tolerance, which requires more assessment and monitoring by a nurse, especially in a patient with fibromyalgia and COPD. Taking the patient's breath sounds involves assessing the patient's respiratory status, which is a nursing responsibility due to the need for clinical judgment. Educating the patient on monitoring fatigue involves providing vital information and should be done by the nurse to ensure comprehensive understanding and tailored recommendations.

Question 3 of 5

A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

Correct Answer: A

Rationale: Unilateral neglect is a condition where a person ignores one side of their body. In this case, the behavior of shaving only one side of the face indicates neglect of the other side. This behavior is suggestive of unilateral neglect as the individual is failing to attend to one side of their body. Choices B, C, and D are not associated with unilateral neglect. Choice B refers to tactile agnosia, a condition where a person cannot recognize objects by touch, not related to ignoring one side of the body. Choice C describes a visual field cut, which is a different visual deficit. Choice D relates to dual-task interference, not specific to ignoring one side of the body.

Question 4 of 5

The client is taking Antabuse and should avoid eating foods that may trigger a disulfiram reaction. The nurse should instruct the client to avoid:

Correct Answer: C

Rationale: The client taking Antabuse should avoid foods that contain alcohol or vinegar as they can trigger a disulfiram reaction. Pickles and vinaigrette dressing often contain vinegar, which the client should avoid. Beef is safe to consume. Choices A, B, and D do not contain alcohol or vinegar, so they are allowed for the client taking Antabuse.

Question 5 of 5

A client has been receiving cyanocobalamin (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?

Correct Answer: D

Rationale: Cyanocobalamin is a B12 medication used for pernicious anemia. A reticulocyte count of 1% indicates the desired effect of the medication, as reticulocytes are immature red blood cells that increase in response to B12 therapy, improving anemia. Neutrophils, basophils, and monocytes are white blood cells and are not directly influenced by B12 injections, making them incorrect choices.

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