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Question 1 of 5.

Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?

A. Assessing and maintaining a patent airway

B. Obtaining vital signs

C. Using the Glasgow Coma Scale to check responsiveness

D. Controlling bleeding

Explanation: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.

Question 2 of 5.

The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?

A. Mashed potatoes

B. Smooth peanut butter

C. Fried fish

D. Rice

Explanation: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.

Question 3 of 5.

The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:

A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.

B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.

C. The client will be more compliant with a medication that allows some feelings of hypomania.

D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.

Explanation: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.

Question 4 of 5.

Which one of the following situations represents a maturational crisis for the family?

A. A four-year-old entering nursery school

B. Development of preeclampsia during pregnancy

C. Loss of employment and health benefits

D. Hospitalization of a grandfather with a stroke

Explanation: A maturational crisis involves normal developmental transitions, such as a child entering nursery school, which can stress family dynamics.

Question 5 of 5.

The nurse is making room assignments for four obstetrical clients. If only one private room is available, it should be assigned to:

A. A multigravida with diabetes mellitus

B. A primigravida with preeclampsia

C. A multigravida with preterm labor

D. A primigravida with hyperemesis gravidarum

Explanation: Preeclampsia requires close monitoring due to risks like seizures or stroke, making a private room essential for a primigravida with this condition.

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