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A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in intracranial pressure (ICP). The nurse should intervene by
- A. increasing oxygen flow.
- B. elevating the head of the bed to 90 degrees.
- C. turning and repositioning the patient on his side.
- D. suctioning the patient at least hourly.
Correct Answer: C
Rationale: Turning and repositioning the patient helps reduce ICP by promoting venous drainage. Elevating the head to 30-45 degrees (not 90) is appropriate; excessive suctioning or oxygen changes may not address ICP directly.
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The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is given annually in:
- A. November
- B. December
- C. January
- D. February
Correct Answer: A
Rationale: Influenza vaccines are typically administered in November, before the peak flu season, to ensure immunity during winter months.
A client with COPD must have the arterial blood gas (ABG) test and asks the nurse to explain the purpose of the test. Which of the following information should the nurse include? Select all that apply.
- A. ABGs measure the levels of carbon dioxide, oxygen, and acidity in the blood.
- B. ABGs help to evaluate the effectiveness of treatment.
- C. ABGs measure the degree of anemia that has developed.
- D. ABGs can help to determine the need for supplemental oxygen.
Correct Answer: A,B,D
Rationale: ABGs measure CO2, O2, and pH (A), evaluate treatment efficacy (B), and guide oxygen therapy (D). Anemia (C) is assessed via hemoglobin, not ABGs.
The nurse is caring for a 16-year-old female with second- and third-degree burns to the face, neck, chest, and arms. The client's wounds are almost healed. The nurse would expect rehabilitation to focus on problems related to:
- A. Body image disturbance
- B. Risk for infection
- C. Sensory perceptual alterations
- D. Activity intolerance
Correct Answer: A
Rationale: Burns to visible areas like the face and neck can significantly impact body image, especially in a teenager, making this a priority during rehabilitation as wounds heal.
The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because:
- A. Grimacing and writhing movements decrease with relaxation and rest.
- B. Hypoactive deep tendon reflexes become more active with rest.
- C. Stretch reflexes are increased with rest.
- D. Fine motor movements are improved by rest.
Correct Answer: A
Rationale: Rest reduces spasticity and involuntary movements in cerebral palsy.
To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.