Nokea
A client with a head injury has an intracranial pressure (ICP) monitor in place. Cerebral perfusion pressure calculations are ordered. If the client's ICP is 22 and the mean pressure reading is 70, what is the client's cerebral perfusion pressure?
- A. 92
- B. 72
- C. 58
- D. 48
Correct Answer: D
Rationale: Cerebral perfusion pressure (CPP) = Mean Arterial Pressure (MAP) - ICP. Given MAP = 70 and ICP = 22, CPP = 70 - 22 = 48. Thus, the answer is 48.
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A client with terminal lung cancer is admitted to the unit. A family member asks the nurse, 'How much longer will it be?' Which response by the nurse is most appropriate?
- A. This must be a terrible situation for you.
- B. I don't know. I'll call the doctor.
- C. I cannot say exactly. What are your concerns at this time?
- D. Don't worry, it will be very soon.
Correct Answer: C
Rationale: This response acknowledges the family's concern, provides an honest answer, and opens the conversation to address their specific worries, promoting therapeutic communication.
A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:
- A. Notify the physician
- B. Make sure the catheter is patent
- C. Administer an antihypertensive
- D. Provide supplemental oxygen
Correct Answer: B
Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.
A client develops anaphylaxis syndrome and loses consciousness after eating fruit salad containing kiwi fruit, to which the client is severely allergic. The nurse is aware that the initial concern is which of the following?
- A. Establish a patent airway.
- B. Administer intravenous fluids.
- C. Administer oxygen at 100% high flow.
- D. Administer epinephrine.
Correct Answer: A
Rationale: In anaphylaxis with unconsciousness, the initial priority is to establish a patent airway (A) to ensure adequate oxygenation. Epinephrine (D), oxygen (C), and fluids (B) follow but are secondary to airway management.
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include:
- A. Decreased pulse rate
- B. Increased blood pressure
- C. Decreased respiratory rate
- D. Increased temperature
Correct Answer: B
Rationale: Severe pain from renal calculi can cause increased blood pressure due to sympathetic nervous system activation and stress response.
The charge nurse witnesses the nursing assistant hitting the client in the long-term care facility. The nursing assistant can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: C
Rationale: Hitting a client is assault, a criminal act of physical harm.