Nokea
A client with a traumatic brain injury has an intracranial pressure (ICP) of $15 \mathrm{mmHg}$ and a mean arterial pressure (MAP) of $90 \mathrm{mmHg}$. What is the cerebral perfusion pressure (CPP)?
- A. 65 mmHg
- B. 75 mmHg
- C. 85 mmHg
- D. 95 mmHg
Correct Answer: B
Rationale: CPP = MAP - ICP; 90 - 15 = 75 mmHg (B). Other options (A, C, D) miscalculate. B is correct. Rationale: CPP of 75 mmHg is within normal (60-100), ensuring brain perfusion, per neurocritical care, critical for TBI outcomes.
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The nurse notices that the client has a hematocrit of 70 percent. This level of hematocrit will most likely affect the vital signs in which of the following ways?
- A. The blood pressure will be elevated.
- B. The pulse will be low.
- C. Temperature will be elevated.
- D. Blood pressure will be low.
Correct Answer: A
Rationale: A 70% hematocrit, abnormally high, increases blood viscosity, elevating blood pressure, not lowering pulse or raising temperature. Nurses monitor this for circulatory strain.
A client with a new diagnosis of COPD is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. You should increase your intake of high-calorie foods.
- B. You should decrease your intake of high-protein foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of high-fiber foods.
Correct Answer: A
Rationale: The correct statement to include in the teaching for a client with a new diagnosis of COPD is that they should increase their intake of high-calorie foods. This is important to help maintain energy levels and manage weight. COPD can lead to increased energy expenditure due to the increased work of breathing, making it crucial to consume adequate calories for energy. High-calorie foods can help prevent weight loss and support overall nutritional status in COPD patients. Choice B is incorrect because high-protein foods are important for maintaining muscle mass in COPD patients. Choice C is incorrect as there is no need to avoid foods that contain lactose unless the client is lactose intolerant. Choice D is incorrect as increasing high-fiber foods may exacerbate symptoms like bloating and gas in COPD patients.
A client with a new diagnosis of chronic kidney disease is being taught about dietary management. Which of the following statements should be included in the teaching?
- A. Increase your intake of protein-rich foods.
- B. Decrease your intake of phosphorus-rich foods.
- C. Avoid foods that contain lactose.
- D. Increase your intake of potassium-rich foods.
Correct Answer: B
Rationale: In chronic kidney disease, decreasing the intake of phosphorus-rich foods is essential as impaired kidney function can lead to difficulty in excreting phosphorus, causing an imbalance. This can result in bone and heart complications. Therefore, educating the client to reduce phosphorus intake is crucial for managing the disease and preventing further complications. Option A is incorrect because excessive protein intake can burden the kidneys. Option C is not directly related to the management of chronic kidney disease. Option D is also incorrect as potassium intake may need to be limited in certain stages of kidney disease.
The nurse manager is conducting an educational session for the nurses on non-selective beta-adrenergic blockers ( $\beta$ blockers). How should the nurse manager accurately describe the mechanism of action of these medications? List the options in order from first to last.
- A. Heart rate and blood pressure are decreased
- B. Epinephrine and norepinephrine actions are blocked
- C. Betaâ‚ and betaâ‚‚ receptor sites are blocked
- D. Cardiac workload and oxygen demand decreases
Correct Answer: C
Rationale: Non-selective beta-adrenergic blockers (e.g., propranolol) inhibit the sympathetic nervous system's effects on betaâ‚ (heart) and betaâ‚‚ (lungs, vessels) receptors. The mechanism sequence is: (1) Betaâ‚ and betaâ‚‚ receptor sites are blocked (C), (2) Epinephrine and norepinephrine actions are blocked (B), (3) Heart rate and blood pressure are decreased (A), (4) Cardiac workload and oxygen demand decreases (D). Blocking beta receptors (C) is the initial step, preventing catecholamines (B) from binding, which reduces heart rate and vasoconstriction (A), ultimately lowering myocardial oxygen demand (D). Incorrect sequencing, like starting with heart rate reduction, skips the pharmacological basis. The CSV requires one answer, so C is chosen as the foundational step. Rationale: Beta blockade directly inhibits receptor activation, a primary action taught in pharmacology education, leading to downstream effects critical for conditions like hypertension or angina, ensuring nurses understand the drug's systemic impact.
In a 24 hour urine specimen started Friday, 9:00 A.M, which of the following if done by a Nurse indicate a NEED for further procedural debriefing?
- A. The nurse ask the client to urinate at 9:00 A.M, Friday and she included the urine in the 24 hour urine specimen
- B. The nurse discards the Friday 9:00 A M urine of the client
- C. The nurse included the Saturday 9:00 A.M urine of the client to the specimen collection
- D. The nurse added preservatives as per protocol and refrigerates the specimen
Correct Answer: A
Rationale: Including 9:00 AM Friday urine pre-start skews 24-hour totals (9 AM Fri-Sat); it's discarded. Discarding start, including end, preserving are correct. Nurses need debrief e.g., timing for accuracy, per standards.