Nokea
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
- A. Bulging fontanelles
- B. Seizure
- C. Headache
- D. Ataxia
Correct Answer: C
Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.
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A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Platelet count
- B. Prothrombin time (PT/INR)
- C. Hemoglobin
- D. Serum potassium
Correct Answer: B
Rationale: Warfarin affects clotting, requiring monitoring of PT/INR to ensure therapeutic anticoagulation. Platelets (A), hemoglobin (C), and potassium (D) are not directly affected.
A client with a history of a heart transplant is receiving Cyclosporine (Sandimmune). The nurse should monitor the client for:
- A. Infection
- B. Hypotension
- C. Hyperkalemia
- D. Weight loss
Correct Answer: A
Rationale: Cyclosporine suppresses immunity, increasing infection risk, requiring vigilant monitoring. Hypotension, hyperkalemia, and weight loss are less common.
A client is in early labor. Her fetus is in a left occipitoanterior (LOA) position; fetal heart sounds are best auscultated just:
- A. Below the umbilicus toward left side of mother's abdomen
- B. Below the umbilicus toward right side of mother's abdomen
- C. At the umbilicus
- D. Above the umbilicus to the left side of mother's abdomen
Correct Answer: A
Rationale: In LOA, the fetus's back is on the mother's left anterior side, so fetal heart sounds are best heard below the umbilicus on the left.
Priapism may be a sign of:
- A. Altered neurological function
- B. Imminent death
- C. Urinary incontinence
- D. Reproductive dysfunction
Correct Answer: A
Rationale: Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. It is not associated with death, urinary incontinence, or reproductive dysfunction as a primary issue.
A client with a history of a thyroidectomy is being discharged. The nurse should teach the client to:
- A. Monitor for signs of hyperthyroidism
- B. Avoid calcium-rich foods
- C. Take the medication at bedtime
- D. Report muscle twitching
Correct Answer: D
Rationale: Muscle twitching post-thyroidectomy may indicate hypocalcemia from parathyroid damage, requiring immediate reporting. Hyperthyroidism, calcium foods, and bedtime dosing are not primary concerns.