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An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
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A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have?
- A. Severe eye pain
- B. Constant blurred vision
- C. Severe headaches, nausea, and vomiting
- D. Reports of seeing halos around objects
Correct Answer: D
Rationale: Open-angle glaucoma is characterized by halos around objects due to increased intraocular pressure, not severe pain or headaches.
A resident of a long-term care facility tells the nurse, 'I'm having a hard time hearing people talk and can't understand the voices on TV.' Which action is most appropriate?
- A. Teach the client about eliminating background noises in the room.
- B. Assess the client's hearing and use an otoscope for examination.
- C. Schedule an appointment with the HCP for bilateral ear irrigations.
- D. Instruct the client to look at the speaker's lips to decipher words.
Correct Answer: B
Rationale: The nurse should assess the client's hearing and perform an otoscopic examination to verify symptoms and identify the cause. Other actions follow assessment.
The client has a hearing loss from a possible acoustic neuroma. The nurse should prepare the client for which diagnostic test to confirm the presence of a tumor?
- A. Tympanometry
- B. Arteriogram of the cranial vessels
- C. Magnetic resonance imaging (MRI)
- D. Auditory canal biopsy
Correct Answer: C
Rationale: MRI with gadolinium enhancement is the most reliable test in determining size and anatomical location of an acoustic neuroma. Tympanometry, arteriogram, and biopsy are not used for this diagnosis.
A client asks the nurse what causes Parkinson's disease. The nurse's correct reply would be that Parkinson's disease is thought to be due to:
- A. a deficiency of dopamine in the brain.
- B. a demyelinating process affecting the central nervous system.
- C. atrophy of the basal ganglia.
- D. insufficient uptake of acetylcholine in the body.
Correct Answer: A
Rationale: Parkinson's disease is caused by a deficiency of dopamine in the brain, leading to motor symptoms.
The nurse is assessing the older adult client with otosclerosis. Which diagnostic characteristics should the nurse associate with otosclerosis?
- A. Bone conduction is greater than air conduction.
- B. Hearing aids are not effective in restoring hearing.
- C. Surgical restoration of hearing is not possible.
- D. Serial audiograms show progressive hearing loss.
Correct Answer: A
Rationale: Otosclerosis impairs the air conduction of sound waves; therefore, bone conduction is typically greater than air conduction. Hearing aids and surgical restoration (stapedectomy) are effective, and progressive hearing loss is detected by serial audiograms.