Nokea
A client sustained a severe head injury to the occipital lobe. The nurse should carefully assess the client for:
- A. Changes in vision
- B. Difficulty in speaking
- C. Impaired judgment
- D. Hearing impairment
Correct Answer: A
Rationale: The occipital lobe processes visual information, so injury to this area is likely to cause visual disturbances, such as blurred vision or visual field deficits.
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The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician
- B. Record the reading as the only action
- C. Turn the client and recheck the reading
- D. Place the client supine
Correct Answer: A
Rationale: An ICP of 66 mmHg is critically high (normal <20 mmHg), indicating severe brain swelling. Notifying the physician is urgent for immediate intervention.
An RN is working with an LPN to care for a group of clients. Which client would the RN most likely assign to the LPN?
- A. a client receiving blood following back surgery
- B. a client who has just returned from having a left heart catheterization
- C. a client with an arterial line who is on a nitroprusside drip to control blood pressure
- D. a client with an abdominal wound requiring dressing changes every 4 hours and PRN
Correct Answer: D
Rationale: The client requiring dressing changes is stable and within the LPN's scope of practice, whereas the other clients require advanced monitoring or interventions suitable for an RN.
The following clients are to be assigned for daily care. The newly licensed nurse should not be assigned to provide primary care for the client with:
- A. Full-thickness burns of the abdomen and upper thighs
- B. A fractured hip scheduled for hip replacement
- C. Ileal reservoir following a cystectomy
- D. Noncardiogenic pulmonary edema (ARDS)
Correct Answer: D
Rationale: ARDS requires complex respiratory management, which is beyond the scope of a newly licensed nurse.
The physician has ordered a low-purine diet for a client with gout. Which protein source is high in purine?
- A. Dried beans
- B. Nuts
- C. Cheese
- D. Eggs
Correct Answer: A
Rationale: Dried beans are high in purines, which can increase uric acid levels and exacerbate gout symptoms.
The nurse is caring for a client 7 days post-burn injury with 60% body surface area involved. The nursing care of this client would primarily focus on:
- A. Meticulous infection-control measures
- B. Fluid-replacement evaluation
- C. Psychological adjustment to the wound
- D. Measurement and application of a pressure garment
Correct Answer: A
Rationale: At 7 days post-burn, infection is a major risk due to open wounds and immunosuppression, making meticulous infection control the primary focus.