Nokea
What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
Correct Answer: B
Rationale: Monitoring neurological status is the priority to detect changes associated with a brain tumor.
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The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity?
- A. Decreased distal pulse.
- B. Inability to move.
- C. Diminished capillary refill.
- D. Coolness to the touch.
Correct Answer: B
Rationale: Inability to move suggests nerve damage, a serious complication requiring immediate evaluation.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.
A nurse is caring for a client with an ileal conduit. When assessing the stoma, which of the following outcomes are undesirable? Select all that apply.
- A. Dermatitis.
- B. Bleeding.
- C. Fungal infection.
- D. Flow of adhesive solvent into the stoma.
- E. Partial obstruction of the stoma from skin cement.
Correct Answer: A,B,C,D,E
Rationale: Dermatitis, bleeding, fungal infections, adhesive solvent flow, and partial obstruction are all undesirable as they indicate complications such as skin irritation, trauma, infection, or improper appliance application that can impair stoma function or client health.
Which of the following is not a risk factor for the development of atherosclerosis?
- A. A family history of early heart attack.
- B. Late onset of puberty.
- C. Total blood cholesterol level greater than 220 mg/dL.
- D. Elevated fasting blood glucose concentration.
Correct Answer: B
Rationale: Late onset of puberty is not a risk factor for atherosclerosis. Family history, high cholesterol, and elevated glucose are established risk factors.
What diet should be implemented for a client who is in the early stages of cirrhosis?
- A. High-calorie, high-carbohydrate.
- B. High-protein, low-fat.
- C. Low-fat, low-protein.
- D. High-carbohydrate, low-sodium.
Correct Answer: A
Rationale: A high-calorie, high-carbohydrate diet (A) supports energy needs in early cirrhosis. High-protein (B) may worsen encephalopathy. Low-fat, low-protein (C) is too restrictive. Low-sodium (D) is relevant for ascites, not early cirrhosis.