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A healthcare provider is assessing a client who has bacterial meningitis. Which of the following findings should the healthcare provider expect?
- A. Nuchal rigidity.
- B. Flaccid paralysis.
- C. Bradycardia.
- D. Hypothermia.
Correct Answer: A
Rationale: Nuchal rigidity is a classic sign of bacterial meningitis and indicates inflammation of the meninges. It is characterized by neck stiffness and pain upon neck flexion. Flaccid paralysis (Choice B) is not typically associated with bacterial meningitis but rather conditions like Guillain-Barre syndrome. Bradycardia (Choice C) and hypothermia (Choice D) are not commonly seen in bacterial meningitis; instead, patients may present with fever, tachycardia, and signs of systemic inflammation.
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A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the nurse indicates an understanding of the teaching?
- A. Stands with feet shoulder-width apart when lifting a client up in bed.
- B. Raises the client's knees before pulling the client up in bed.
- C. Uses a mechanical lift to move a client from bed to chair.
- D. Places a gait belt around the client's waist before assisting the client to stand.
Correct Answer: C
Rationale: Using a mechanical lift is an appropriate ergonomic technique as it reduces the risk of injury to both the nurse and the client by promoting safe client handling practices. Choice A is incorrect as standing with feet shoulder-width apart provides better balance and stability during lifting. Choice B is incorrect as raising the client's knees is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's waist is a safety measure but does not specifically demonstrate an understanding of ergonomic principles.
A healthcare provider is assessing a newborn who has a patent ductus arteriosus. Which of the following findings should the provider expect?
- A. Continuous murmur.
- B. Absent peripheral pulses.
- C. Increased blood pressure.
- D. Bounding pulses.
Correct Answer: A
Rationale: A continuous murmur is a classic finding in a newborn with patent ductus arteriosus. This murmur is typically heard between the first and second heart sounds and throughout systole. Absent peripheral pulses (choice B) are not typically associated with patent ductus arteriosus. Increased blood pressure (choice C) and bounding pulses (choice D) are not commonly seen with this condition. Therefore, the correct answer is A.
A nurse is caring for a client who is postoperative following a thyroidectomy. The nurse should identify that which of the following client reports is an indication of hypocalcemia?
- A. Constipation
- B. Frequent urination
- C. Numbness and tingling of the fingers
- D. Increased thirst
Correct Answer: C
Rationale: The correct answer is C: 'Numbness and tingling of the fingers.' Post-thyroidectomy, hypocalcemia is a concern due to potential damage to the parathyroid glands that regulate calcium levels. Numbness and tingling of the fingers are classic signs of hypocalcemia. Constipation (Choice A) is not typically associated with hypocalcemia. Frequent urination (Choice B) is more indicative of conditions like diabetes or a urinary tract infection. Increased thirst (Choice D) is commonly seen in conditions such as diabetes insipidus or uncontrolled diabetes mellitus, not specifically related to hypocalcemia.
A client is receiving continuous IV nitroprusside for severe hypertension. Which action should the nurse take?
- A. Keep calcium gluconate at the bedside.
- B. Monitor blood pressure every 2 hours.
- C. Limit IV exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take is to limit IV exposure to light. Nitroprusside is light-sensitive, and exposure to light can lead to its degradation, potentially reducing its efficacy in treating severe hypertension. Keeping calcium gluconate at the bedside (Choice A) is not directly related to managing nitroprusside infusion. While monitoring blood pressure every 2 hours (Choice B) is important in managing hypertension, it is not the immediate action required to ensure medication efficacy. Attaching an inline filter to the IV tubing (Choice D) may help filter particles but does not address the critical concern of light sensitivity associated with nitroprusside administration.
A nurse is planning care for a client who is postoperative following a bowel resection. Which of the following interventions should the nurse include?
- A. Encourage the client to drink adequate fluids daily.
- B. Administer pain medication as needed.
- C. Instruct the client to splint the incision with a pillow.
- D. Encourage the client to eat a balanced diet.
Correct Answer: C
Rationale: The correct intervention for a client post-bowel resection is to instruct the client to splint the incision with a pillow. This technique helps prevent dehiscence, which is the separation of wound edges, and reduces pain when coughing or moving. Splinting supports the incision site, decreasing tension on the wound. Encouraging the client to drink adequate fluids promotes hydration and aids in recovery, but a specific volume like 1,000 mL mentioned in choice A is not essential. Pain medication should be administered as needed for adequate pain control, not necessarily before every meal. Instructing the client to eat a balanced diet, including adequate protein, is crucial for wound healing and overall recovery, rather than limiting protein intake.