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A nurse frequently treats patients in the 72-hour period after a stroke has occurred. The nurse would be most concerned about which of these assessment findings?
- A. INR is 3 seconds long
- B. Heart rate is 110 beats per minute
- C. Intracranial Pressure is 22 mmHg
- D. Blood pressure is 140/80
Correct Answer: C
Rationale: The nurse would be most concerned about the assessment finding of an Intracranial Pressure (ICP) reading of 22 mmHg in a patient 72 hours post-stroke. Elevated ICP can indicate increased risk of edema and further brain damage. A target ICP should ideally be maintained at less than or equal to 15-20 mmHg. While the other options may also be important to monitor, an elevated ICP poses a more immediate threat to the patient's neurological status and requires prompt attention.
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Following surgery to correct cryptorchidism, what is the priority action that the nurse should include in the plan of care?
- A. Prevent tension on the suture.
- B. Monitor urine for glucose and acetone.
- C. Encourage oral fluids, and monitor intake and output.
- D. Encourage coughing and deep breathing every hour.
Correct Answer: A
Rationale: The correct answer is to prevent tension on the suture. After surgery for cryptorchidism, the testicle is held in position by an internal suture that should not be dislodged. Immobilization of the area for a week is crucial to prevent complications like bleeding and infection. Monitoring urine for glucose and acetone is unrelated to this surgery. While maintaining hydration is important, forcing fluids is not necessary. Encouraging coughing and deep breathing every hour may be a postoperative consideration, but it is not the priority for this specific surgery.
The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?
- A. A high WBC count and decreased level of consciousness
- B. A high WBC count and manic activity
- C. A low WBC count and manic activity
- D. A low WBC count and decreased level of consciousness
Correct Answer: A
Rationale: The correct answer is 'A high WBC count and decreased level of consciousness.' Meningitis is often caused by an infectious organism, leading to an increase in Intracranial Pressure (ICP), which can result in decreased level of consciousness. While meningitis can trigger an inflammatory response, it typically presents with an elevated white blood cell (WBC) count rather than a low WBC count. Manic activity is not a common clinical manifestation of meningitis; instead, patients may exhibit altered mental status, confusion, or lethargy.
The parent of an infant diagnosed with gastroesophageal reflux disease is receiving feeding instructions from the nurse. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?
- A. Provide smaller, more frequent feedings.
- B. Burp the infant frequently during feedings.
- C. Thin the feedings by adding water to the formula.
- D. Thicken the feedings by adding rice cereal to the formula.
Correct Answer: D
Rationale: Gastroesophageal reflux disease involves the backward flow of gastric contents into the esophagus due to sphincter issues. To reduce episodes of emesis, it is recommended to thicken feedings by adding rice cereal to the formula. This helps to weigh down the contents in the stomach, making regurgitation less likely. Providing smaller, more frequent feedings and burping the infant frequently are beneficial strategies for gastroesophageal reflux. However, in this case, thickening the feedings is the most appropriate intervention. Thinning the feedings by adding water to the formula is not recommended as it can decrease the caloric density of the formula and may not help in reducing reflux.
A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma.
Which of the following indicates that the patient has a correct understanding of the expected outcomes
following treatment?
- A. "I should be experiencing less blurriness in my central field of vision"
- B. "This medication won't help my vision at all, but will keep it from getting worse."
- C. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
- D. "This medication will help my eye restor intraocular fluid and increase intraocular pressure"
Correct Answer: B
Rationale: Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.
The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?
- A. Polyuria
- B. Weight gain
- C. Hypotension
- D. Grossly bloody urine
Correct Answer: B
Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.