Nokea
A client with a head injury asks why he cannot have something for his headache. The nurse's response is based on the understanding that analgesics could:
- A. Counteract the effects of antibiotics
- B. Elevate the blood pressure
- C. Mask symptoms of increasing intracranial pressure
- D. Stimulate the central nervous system
Correct Answer: C
Rationale: Analgesic medication does not counteract the effects of antibiotics. Analgesic medication may lower blood pressure elevated due to anxiety. Analgesic medication, especially CNS depressants, is not given if there is danger of increasing ICP, because neurological changes may not be apparent. Also, further depression of the CNS is contraindicated. Analgesics do not stimulate the CNS.
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The nurse is caring for a client with a history of a stroke who has dysphagia. The nurse should:
- A. Offer thin liquids
- B. Position the client upright for meals
- C. Feed the client quickly
- D. Use a straw for fluids
Correct Answer: B
Rationale: Positioning upright during meals reduces aspiration risk in dysphagia post-stroke. Thickened liquids, slow feeding, and avoiding straws are also recommended.
Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of iced tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and A), and zinc. Baked chicken breast (protein), broccoli (vitamin C), wheat roll (carbohydrates), and an orange (vitamin C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).
In teaching the client about proper umbilical cord care, the nurse recommends that:
- A. Petrolatum be placed around the cord after the sponge bath
- B. A belly binder be applied to prevent umbilical hernia
- C. The area be cleansed at diaper changes with alcohol and inspected for redness or drainage
- D. The cord clamp be left on until the cord stump separates
Correct Answer: C
Rationale: Petrolatum does not allow the cord to dry and will encourage infection. Belly binders do not facilitate drying of the cord and will encourage abdominal relaxation. Frequent applications of alcohol will facilitate drying and discourage infection. The cord clamp can be removed in 24 hours. Leaving it on is cumbersome and could pull on the cord unnecessarily.
A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis, suggesting inadequate ventilation and the need for mechanical ventilation. PCO2 58 (A) and HCO3 30 (D) are elevated but less critical, and SaO2 90 (B) is low but not definitive.
The nurse enters the playroom and finds an 8-year-old child having a grand mal seizure. Which one of the following actions should the nurse take?
- A. Place a tongue blade in the child's mouth.
- B. Restrain the child so he will not injure himself.
- C. Go to the nurses station and call the physician.
- D. Move furniture out of the way and place a blanket under his head.
Correct Answer: D
Rationale: The nurse should not put anything in the child's mouth during a seizure; this action could obstruct the airway. Restraining the child's movements could cause constrictive injury. Staying with the child during a seizure provides protection and allows the nurse to observe the seizure activity. The nurse should provide safety for the child by moving objects and protecting the head.