Nokea
A client who experienced a cardiac arrest and resuscitation is exhibiting characteristics of mild anoxic brain injury. Which of the following characteristics does the nurse expect her to exhibit? Select all that apply.
- A. Decreased ability to concentrate.
- B. Seizures.
- C. Memory impairment.
- D. Semicomatose state.
- E. Decreased balance.
- F. Restlessness.
Correct Answer: A,C,E,F
Rationale: Mild anoxic brain injury may cause decreased concentration (A), memory impairment (C), decreased balance (E), and restlessness (F). Seizures (B) and semicomatose state (D) are more typical of severe injury.
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All of the following are parts of the middle ear EXCEPT the
- A. pinna.
- B. incus.
- C. stapes.
- D. malleus.
Correct Answer: A
Rationale: The middle ear includes the incus, stapes, and malleus (ossicles). The pinna is part of the outer ear.
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.
A preterm infant with sepsis is receiving Gentamycin (garamycin). Which physiological alteration places the preterm infant at increased risk for toxicity related to aminoglycoside therapy?
- A. Lack of subcutaneous fat deposits
- B. Immature central nervous system
- C. Presence of fetal hemoglobin
- D. Immaturity of the renal system
Correct Answer: D
Rationale: The immature renal system in preterm infants reduces the ability to excrete aminoglycosides like Gentamycin, increasing the risk of toxicity.
The physician has ordered a homocysteine blood level on a client. The nurse recognizes that the results will be increased in a client with a deficiency in:
- A. Vitamin B12
- B. Vitamin C
- C. Vitamin A
- D. Vitamin E
Correct Answer: A
Rationale: Homocysteine levels rise with vitamin B12 deficiency, as B12 is needed for homocysteine metabolism, unlike other vitamins listed.
The nurse in the ER has received report of four clients en route to the emergency department. Which client should the nurse see first? A client with:
- A. Third-degree burns to the face and neck area, with singed nasal hairs
- B. Second-degree burns to each leg and thigh area, who is alert and oriented
- C. A chemical burn that has been removed and liberally flushed before admission
- D. An electrical burn entering and leaving on the same side of the body
Correct Answer: A
Rationale: Third-degree burns to the face and neck with singed nasal hairs suggest airway burns, a life-threatening condition requiring immediate airway assessment and management.