Nokea
A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?
- A. BP 120/80, pulse 120, respirations 20
- B. BP 180/98, pulse 50, temperature 102°F
- C. BP 98/60, pulse 132, temperature 97.6°F
- D. BP 170/90, pulse 80, respirations 24
Correct Answer: B
Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.
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The nurse is reinforcing teaching with a client in the postpartum period who is breastfeeding and has breast engorgement. Which of the following information should the nurse include?
- A. Apply ice packs to your breasts for 15 to 20 minutes before breastfeeding
- B. Allow your baby to nurse for at least 10 to 15 minutes on each breast
- C. Temporarily decrease the frequency of your breastfeeding
- D. Avoid taking NSAIDs for discomfort while breastfeeding
Correct Answer: B
Rationale: Nursing for 10-15 minutes per breast relieves engorgement by emptying milk ducts. Ice packs are used after, not before, feeding; decreasing frequency worsens engorgement; and NSAIDs are safe for breastfeeding.
The client taking a bronchodilator tells the nurse that he is going to begin a smoking cessation program when he is discharged. The nurse should tell the client to notify the doctor if his smoking pattern changes because he will:
- A. Need his medication dosage adjusted
- B. Require an increase in antitussive medication
- C. No longer need annual influenza immunization
- D. Not derive as much benefit from inhaler use
Correct Answer: A
Rationale: Changes in smoking patterns should be discussed with the physician because they have an impact on the amount of medication needed. Answer B is incorrect because clients with COPD are placed on expectorants, not antitussives. Answer C is incorrect because an annual influenza vaccine is recommended for all those with lung disease. Answer D is incorrect because benefits from inhaler use should be increased when the client stops smoking.
The women’s health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?
- A. Client reports heavy menstrual cycles
- B. History of breast cancer in maternal aunt
- C. History of deep venous thrombosis
- D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m^2
Correct Answer: C
Rationale: Deep venous thrombosis is a contraindication for estrogen-containing contraceptives like the patch due to increased clotting risk. Heavy menses, family history of breast cancer, and obesity are less critical.
The nurse is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?
- A. Ictal phase
- B. Aural phase
- C. Postictal phase
- D. Prodromal phase
Correct Answer: C
Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.
A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.