Nokea
A client with increased intracranial pressure is receiving Osmitrol (Mannitol) and Furosemide (Lasix). The nurse recognizes that these two drugs are given to reverse which effect?
- A. Energy failure
- B. Excessive intracellular calcium
- C. Cellular edema
- D. Excessive glutamate release
Correct Answer: C
Rationale: Mannitol and Furosemide reduce cellular edema by promoting diuresis and osmotic fluid shifts, lowering ICP. Energy failure (A), calcium (B), and glutamate (D) are not directly targeted.
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The client is diagnosed with a tension pneumothorax. Which intervention should the nurse anticipate?
- A. Insertion of a chest tube
- B. Administration of oxygen at 2 L/min
- C. Needle decompression
- D. Bronchodilator therapy
Correct Answer: C
Rationale: Tension pneumothorax, a medical emergency, requires needle decompression to relieve pressure on the lung and mediastinum, followed by chest tube insertion. Oxygen and bronchodilators are secondary.
A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?
- A. Decreased appetite
- B. A low-grade fever
- C. Chest congestion
- D. Constant swallowing
Correct Answer: D
Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.
A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the high-humidity tent is to:
- A. Prevent insensible water loss
- B. Provide a moist environment with oxygen at 30%
- C. Prevent dehydration and reduce fever
- D. Liquefy secretions and relieve laryngeal spasm
Correct Answer: D
Rationale: High-humidity tents in croup moisten airways, liquefying secretions and relieving laryngeal spasms, easing breathing. Oxygen levels are not necessarily 30%, and dehydration or fever is secondary.
The nurse is teaching the client with hepatitis B regarding transmission. The nurse should instruct the client to do which of the following?
- A. Refrain from eating fresh fruits and vegetables.
- B. Avoid using another family member's toothbrush.
- C. Clean the commode after each bowel movement.
- D. Boil water prior to drinking and place open containers in the refrigerator.
- E. Inform the dentist of his diagnosis.
Correct Answer: B, E
Rationale: Hepatitis B is transmitted via blood and bodily fluids. Avoiding sharing toothbrushes (B) prevents transmission through saliva or blood. Informing the dentist (E) ensures precautions during procedures. Eating fresh produce (A), cleaning the commode (C), and boiling water (D) are unrelated to hepatitis B transmission.
A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Identity versus role confusion
- B. Integrity versus despair
- C. Intimacy versus isolation
- D. Generativity versus self-absorption
Correct Answer: D
Rationale: Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.