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A client with pancreatitis has been transferred to the intensive care unit. The nurse assesses a pulmonary arterial wedge pressure (PAWP) of 14 mmHg. Based on this finding, the nurse would want to further assess for what additional correlating wedge pressure data?
- A. A drop in blood pressure
- B. Rales on chest auscultation
- C. A temperature elevation
- D. Dry mucous membranes
Correct Answer: B
Rationale: PAWP of 14 mmHg is elevated, suggesting left ventricular overload. Rales (B) indicate pulmonary edema, correlating with high PAWP. BP drop (A), fever (C), and dry membranes (D) are unrelated.
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A client was prescribed a major tranquilizer 2 months ago. One month ago she was placed on benztropine (Cogentin). What would indicate that benztropine therapy is effective?
- A. Smooth, coordinated voluntary movement
- B. Tremors
- C. Rigidity
- D. Muscle weakness
Correct Answer: A
Rationale: Benztropine alleviates extrapyramidal side effects of tranquilizers, such as tremors and rigidity, resulting in smooth, coordinated movements.
A client with a history of gout is receiving Allopurinol (Zyloprim). The nurse should teach the client to:
- A. Increase fluid intake
- B. Avoid dairy products
- C. Take the medication on an empty stomach
- D. Limit protein intake
Correct Answer: A
Rationale: Allopurinol reduces uric acid, and increased fluid intake promotes uric acid excretion, preventing kidney stones. Dairy, empty stomach, and protein limits are not necessary.
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
- A. Hiccups
- B. Anorexia
- C. Mental confusion
- D. Fetor hepaticus
Correct Answer: C
Rationale: One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Only contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
A group of nursing students at a local preschool day care center are going to screen each child's fine and gross motor, language, and social skills. The students will use which one of the most widely used screening tests?
- A. Revised Prescreening Developmental Questionnaire
- B. Goodenough Draw-a-Person Screening Test
- C. Denver Developmental Screening Test
- D. Caldwell Home Inventory
Correct Answer: C
Rationale: The Revised Prescreening Developmental Questionnaire is more age appropriate and offers simplified parent scoring and easier comparison. It is used by parents instead of professionals. The Goodenough Draw-a-Person test is used to assess intellectual development. The Denver Developmental Screening Test is one of the most widely used screening tests. It offers a concise, easy-to-administer, systematic approach to assessing the preschool child. It is widely used because of its reliability and validity. The Caldwell Home Inventory is used to assess the home environment in areas of social, emotional, and cognitive supports.