Questions 53

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ATI RN Custom Nursing 221 Exam 4 Questions

Extract:


Question 1 of 5

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F) and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

Correct Answer: B

Rationale: Shivering can counteract the cooling effect of the hypothermia blanket.

Question 2 of 5

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture. Which of the following actions is most likely to facilitate resolution of the headache?

Correct Answer: A

Rationale: Increasing fluid intake replaces cerebrospinal fluid, alleviating headache.

Question 3 of 5

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Correct Answer: D

Rationale: Scatter rugs in the kitchen can cause falls, posing a safety risk.

Question 4 of 5

While performing an admission assessment for a client, the nurse notes that the client has varicose veins with ulcerations and lower extremity edema with a report of a feeling of heaviness. Which of the following nursing diagnoses should the nurse identify as being the priority in the client's care?

Correct Answer: B

Rationale: Impaired tissue perfusion is the priority due to poor blood flow causing ulcerations and edema.

Question 5 of 5

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Correct Answer: A

Rationale: Sudden headache, vomiting, and high blood pressure suggest hemorrhagic stroke.

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