Nokea
A client with a head injury is receiving mechanical ventilation. Which finding indicates to the nurse that the client may be experiencing increased intracranial pressure (ICP)?
- A. Widening pulse pressure
- B. Sudden drop in heart rate
- C. A decrease in urine output
- D. Elevated blood pressure and widening pulse pressure
Correct Answer: D
Rationale: In a client with increased intracranial pressure (ICP), the body's compensatory mechanisms lead to an elevation in blood pressure and a widening pulse pressure. This occurs due to the body's attempt to maintain cerebral perfusion. Therefore, elevated blood pressure and widening pulse pressure are classic signs of increased ICP and necessitate immediate attention. Choices A, B, and C are incorrect because a widening pulse pressure, sudden drop in heart rate, or decreased urine output are not specific indicators of increased ICP.
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Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?
- A. Egg whites, toast, and coffee.
- B. Bran muffin, mixed fruits, and orange juice.
- C. Granola and grapefruit juice.
- D. Bagel with jelly and skim milk.
Correct Answer: D
Rationale: The correct answer is D, 'Bagel with jelly and skim milk.' This choice includes skim milk, a good source of calcium, which is important for osteoporosis management. It also avoids foods that inhibit calcium absorption. Osteoporosis dietary management emphasizes increased calcium intake and reducing foods that hinder calcium absorption. Choice A only provides proteins but lacks calcium. Choice B offers fruits and a bran muffin, but it lacks a good source of calcium. Choice C has granola but misses a significant source of calcium.
A female client has been taking a high dose of prednisone, a corticosteroid, for several months. After stopping the medication abruptly, the client reports feeling 'very tired'. Which nursing intervention is most important for the nurse to implement?
- A. Measure vital signs
- B. Auscultate breath sounds
- C. Palpate the abdomen
- D. Observe the skin for bruising
Correct Answer: A
Rationale: The correct answer is to measure vital signs. Abrupt withdrawal of exogenous corticosteroids can precipitate adrenal insufficiency, potentially leading to shock. Monitoring vital signs is crucial in identifying any signs of adrenal insufficiency, such as hypotension or tachycardia. Auscultating breath sounds (choice B) may be important in other situations, such as respiratory conditions, but it is not the priority in this case. Palpating the abdomen (choice C) and observing the skin for bruising (choice D) are not directly related to the potential complications of corticosteroid withdrawal and adrenal insufficiency.
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should be monitored closely?
- A. Serum potassium
- B. Hemoglobin
- C. Serum sodium
- D. White blood cell count
Correct Answer: A
Rationale: The correct answer is A: Serum potassium. When a client with chronic kidney disease is undergoing erythropoietin therapy, monitoring serum potassium levels is crucial. Erythropoietin can stimulate red blood cell production, which may lead to an increase in potassium levels, predisposing the client to hyperkalemia. Monitoring serum potassium levels helps in early detection of hyperkalemia and appropriate intervention. Choices B, C, and D are incorrect because although hemoglobin, serum sodium, and white blood cell count are important parameters to monitor in various clinical conditions, they are not specifically associated with erythropoietin therapy in chronic kidney disease.
A 12-year-old boy has a body mass index (BMI) of 28, a systolic pressure, and a glycosylated hemoglobin (HBA1C) of 7.8%. Which selection indicates that his mother understands the management of his diet?
- A. One whole-wheat bagel with cream cheese, two strips of bacon, six ounces of orange juice.
- B. Two eggs with toast and butter, 8 ounces of milk.
- C. Fresh fruit salad with low-fat yogurt.
- D. Pancakes with syrup and sausage links.
Correct Answer: C
Rationale: The correct answer is C. Fresh fruit salad with low-fat yogurt is a healthier choice for managing the diet of a 12-year-old boy with a high BMI and elevated HBA1C. This choice provides a good balance of nutrients, fiber, and low-fat content, helping to lower BMI and maintain healthy blood sugar levels. Choices A, B, and D are less ideal as they contain higher levels of refined carbohydrates, saturated fats, and sugars, which can contribute to weight gain and worsen blood sugar control in this scenario.
A client with a history of chronic heart failure is admitted with shortness of breath. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Chest X-ray
- B. Arterial blood gases (ABGs)
- C. Echocardiogram
- D. Electrocardiogram (ECG)
Correct Answer: C
Rationale: The correct answer is an echocardiogram. This diagnostic test is crucial in assessing ventricular function and identifying the cause of shortness of breath in a client with heart failure. It provides valuable information about the heart's structure, function, and blood flow. While a chest X-ray may show signs of heart failure, it does not directly assess cardiac function like an echocardiogram does. Arterial blood gases (ABGs) are useful to evaluate oxygenation and acid-base balance but do not provide information specific to heart function. An electrocardiogram (ECG) assesses the heart's electrical activity and rhythm, which is important but may not provide the detailed structural information needed in this scenario.