Nokea
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The physician orders manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this order based on the understanding that this action will accomplish which of the following?
- A. Decrease intracranial pressure.
- B. Ensure a patent airway.
- C. Lower the arousal level.
- D. Produce hypoxia.
Correct Answer: A
Rationale: Hyperventilation lowers PaCO2, causing vasoconstriction and reducing intracranial pressure in brain tumor patients.
You may also like to solve these questions
A parent asks the nurse about head lice (pediculosis capitis) infestation during a visit to the clinic. Which of the following symptoms should the nurse tell the parent is most common in a child infected with head lice?
- A. Itching of the scalp.
- B. Scaling of the scalp.
- C. Serous weeping on the scalp surface.
- D. Pinpoint hemorrhagic spots on the scalp surface.
Correct Answer: A
Rationale: Itching is the hallmark symptom of head lice due to an allergic reaction to lice saliva.
When obtaining a history from the parents of a child diagnosed with diarrhea due to Salmonella, the nurse should ask the parents if the child has been exposed to which of the following possible sources of infection?
- A. Nonrefrigerated custard.
- B. A pet canary.
- C. Undercooked eggs.
- D. Unwashed fruit.
Correct Answer: C
Rationale: Undercooked eggs are a common source of Salmonella infection.
The nurse formulates the nursing diagnosis Imbalanced Nutrition: Less than body requirements related to negative feeding patterns for a 5-month-old infant diagnosed with failure to thrive. To meet the short-term outcomes of the infant's plan of care, the nurse should expect to do which of the following?
- A. Instruct the parents in proper feeding techniques.
- B. Give infant formula that has 24 calories/ounce.
- C. Provide consistent staff to care for the infant.
- D. Allow the infant to sit in a high chair during feedings.
Correct Answer: A
Rationale: Teaching proper feeding techniques corrects negative patterns, improving intake. Higher-calorie formula or consistent staff are secondary, and high chairs are unsuitable for a 5-month-old.
A 6-month-old child is discharged with a urinary stent after a procedure to repair a hypospadias. The nurse should tell the parents to:
- A. Avoid tub baths until the stent is removed.
- B. Measure output in the urinary bag.
- C. Avoid drinking fruit juice.
- D. Clean the tip of the penis 3 times a day with soap and water.
Correct Answer: A
Rationale: Avoiding tub baths prevents infection.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
- A. Enroll in a risk management plan.
- B. Egypt in a risk management plan.
- C. Begin an effective form of birth control.
- D. Temporarily give up sports.
Correct Answer: C
Rationale: Isotretinoin has a high risk of teratogenicity, requiring strict contraception to prevent pregnancy during treatment. A risk management plan (e.g., iPLEDGE) is also required, but the most critical initial step emphasized is effective birth control.