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A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the I.V. line. Which nursing intervention protects the client without increasing her increased intracranial pressure (ICP)?
- A. Place her in a jacket restraint.
- B. Wrap her hands in soft "mitten" restraints.
- C. Tuck her arms and hands under the drawsheet.
- D. Apply a wrist restraint to each arm.
Correct Answer: B
Rationale: Soft mitten restraints prevent the client from pulling out the I.V. without restricting circulation or increasing ICP, unlike jacket or wrist restraints, which can cause agitation or pressure. Tucking arms under a drawsheet is unsafe and ineffective.
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An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be made to be removed for which of the following complications?
- A. Vertigo.
- B. Bell's palsy.
- C. Hypoventilation.
- D. Loss of gag reflex.
Correct Answer: C
Rationale: Posterior packing can obstruct the airway, leading to hypoventilation, a serious complication. Vertigo, Bell's palsy, and loss of gag reflex are not directly associated with posterior packing.
A client on hemodialysis reports muscle cramps. The nurse should:
- A. Increase dialysate flow.
- B. Check electrolyte levels.
- C. Administer a diuretic.
- D. Encourage ambulation.
Correct Answer: B
Rationale: Muscle cramps may indicate electrolyte imbalances, requiring lab assessment.
A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, 'How does glaucoma damage my eyesight?' The nurse's reply should be based on the knowledge that COAG:
- A. Results from chronic eye inflammation.
- B. Causes increased intraocular pressure.
- C. Leads to detachment of the retina.
- D. Is caused by decreased blood flow to the retina.
Correct Answer: B
Rationale: Chronic open-angle glaucoma causes increased intraocular pressure, which damages the optic nerve over time, leading to vision loss.
What should the nurse assess in a client receiving anticonvulsant therapy?
- A. Liver function.
- B. Blood pressure.
- C. Pain levels.
- D. Skin integrity.
Correct Answer: A
Rationale: Liver function is assessed due to the potential hepatotoxicity of anticonvulsant medications.
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema?
- A. To promote oxygen intake.
- B. To strengthen the diaphragm.
- C. To strengthen the intercostal muscles.
- D. To promote carbon dioxide elimination.
Correct Answer: D
Rationale: Pursed-lip breathing prolongs exhalation, reducing air trapping and promoting CO2 elimination in emphysema. It does not directly increase oxygen intake or strengthen muscles.