Nokea
A nurse creates a care plan for a client diagnosed with a cerebellar brain tumor. The correct nursing diagnosis for this client is 'Client at risk for injury related to
- A. impaired balance.'
- B. decreased visual acuity.'
- C. decreased level of consciousness.'
- D. impaired ability to make decisions.'
Correct Answer: A
Rationale: Cerebellar tumors impair coordination and balance, increasing fall risk, making 'impaired balance' the most relevant diagnosis.
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A 52-year-old client is undergoing menopause. Which of the following physical sign or symptom is often attributed to decreased estrogen production associated with menopause?
- A. Weight loss
- B. Excessive sleeping
- C. Increased fat deposits on hips and abdomen
- D. Increased metabolic rate
Correct Answer: C
Rationale: Decreased estrogen in menopause often leads to increased fat deposits on hips and abdomen (C). Weight loss (A), excessive sleeping (B), and increased metabolic rate (D) are not typical.
A nurse has received report on the day's clients. In planning morning rounds, which client is the priority to see?
- A. a new admission with a UTI and fever
- B. a client who is NPO for surgery later in the morning
- C. a client complaining of nausea after eating breakfast
- D. a client recently complaining of shortness of breath
Correct Answer: D
Rationale: Shortness of breath indicates a potential respiratory or cardiac issue, making this client the priority for immediate assessment.
A client with psychotic depression is receiving haloperidol (Haldol). Which of the following adverse effects is associated with haloperidol?
- A. Akathisia
- B. Cataracts
- C. Diaphoresis
- D. Polyuria
Correct Answer: A
Rationale: Akathisia, a movement disorder characterized by restlessness, is a common extrapyramidal side effect of haloperidol.
Based on clinical findings, the physician suspects that a 65-year-old client has kidney disease and has ordered a blood-urea-nitrogen (BUN) test. Which of the following results is within normal limits?
- A. 5 mg/dL
- B. 15 mg/dL
- C. 40 mg/dL
- D. 100 mg/dL
Correct Answer: B
Rationale: Normal BUN is 7-20 mg/dL, so 15 mg/dL (B) is within range. Other values (A, C, D) are too low or high.
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm is a contraindication for digoxin administration due to the risk of worsening bradycardia, so the nurse should withhold the dose and notify the physician.