Nokea
A nurse in the emergency department is observing a 4-year-old child for signs of increased intracranial pressure after a fall from a bicycle, resulting in head trauma. Which of the following signs or symptoms would be cause for concern?
- A. Bulging anterior fontanel
- B. Repeated vomiting
- C. Signs of sleepiness at 10 PM
- D. Inability to read short words from a distance of 18 inches
Correct Answer: B
Rationale: Increased intracranial pressure after head trauma can lead to serious complications. Repeated vomiting is a concerning sign as it can indicate stimulation of the vomiting center within the brainstem due to increased pressure. This can be an early indicator of raised intracranial pressure and the need for urgent medical intervention. Bulging anterior fontanel may not be immediately apparent in a 4-year-old child and is more common in infants. Signs of sleepiness at a particular time of day are not specific to increased intracranial pressure. Inability to read short words from a distance of 18 inches may indicate vision problems but is not directly related to intracranial pressure.
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During shift change, a healthcare professional is reviewing a patient's medication. Which of the following medications would be contraindicated if the patient were pregnant?
- A. Warfarin (Coumadin)
- B. Celecoxib (Celebrex)
- C. Clonidine (Catapres)
- D. Transdermal nicotine (Habitrol)
Correct Answer: A
Rationale: Warfarin (Coumadin) is contraindicated in pregnancy due to its pregnancy category X classification. It is associated with central nervous system defects, spontaneous abortion, stillbirth, prematurity, hemorrhage, and ocular defects when administered at any time during pregnancy. Fetal warfarin syndrome can occur when given during the first trimester. Celecoxib (Celebrex) is a pregnancy category C medication, which means there may be risks but benefits may outweigh them. Clonidine (Catapres) is also a pregnancy category C drug, and while animal studies have shown adverse effects on the fetus, there are limited human studies. Transdermal nicotine (Habitrol) is classified as a pregnancy category D drug, indicating positive evidence of fetal risk, but benefits may still warrant its use in pregnant women with serious conditions.
A client with myocardial infarction is receiving tissue plasminogen activator, alteplase (Activase, tPA). While on the therapy, the nurse plans to prioritize which of the following?
- A. Observe for neurological changes
- B. Monitor for any signs of renal failure
- C. Check the food diary
- D. Observe for signs of bleeding
Correct Answer: D
Rationale: The priority concern for a client receiving thrombolytic medication, such as tissue plasminogen activator (alteplase), is to monitor for signs of bleeding. Thrombolytics work by converting plasminogen to plasmin, which degrades fibrin. This process can lead to the breakdown of both fibrin-bound plasminogen on thrombi surfaces and unbound plasminogen in the plasma. The resulting plasmin can degrade fibrin, fibrinogen, factor V, and factor VIII. Observing for signs of bleeding is crucial due to the increased risk of hemorrhage associated with thrombolytic therapy. Monitoring for neurological changes, signs of renal failure, or checking the food diary are not the immediate priorities compared to detecting and managing potential bleeding complications.
Which of the following conditions most commonly causes acute glomerulonephritis?
- A. A congenital condition leading to renal dysfunction.
- B. Prior infection with group A Streptococcus within the past 10-14 days.
- C. Viral infection of the glomeruli.
- D. Nephrotic syndrome.
Correct Answer: B
Rationale: Acute glomerulonephritis is most commonly caused by the immune response to a prior
upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
A patient with leukemia is receiving chemotherapy that is known to depress bone marrow. A CBC (complete blood count) reveals a platelet count of 25,000/microliter. Which of the following actions related specifically to the platelet count should be included in the nursing care plan?
- A. Monitor for fever every 4 hours.
- B. Require visitors to wear respiratory masks and protective clothing.
- C. Consider transfusion of packed red blood cells.
- D. Check for signs of bleeding, including examination of urine and stool for blood.
Correct Answer: D
Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (Choice A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (Choice B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (Choice C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.
A nurse is assessing a client who is post-op day #3 after an abdominal hernia repair. After a bout of harsh coughing, the client states, 'it feels like something gave way.' The nurse assesses his abdomen and notes an evisceration from the surgical site. What is the next action of the nurse?
- A. Turn the client on his side
- B. Push the abdominal contents back inside the wound using sterile gloves
- C. Ask the client to take a breath and hold it
- D. Cover the intestine with sterile saline dressings
Correct Answer: D
Rationale: A wound evisceration occurs when the edges of an abdominal wound separate, allowing the coils of the intestine to protrude outside of the body. The nurse should notify the physician at once if this occurs. While waiting for treatment, the nurse should cover the intestines with sterile gauze soaked in saline. Turning the client on his side or asking the client to take a breath and hold it are not appropriate actions in this situation. Pushing the abdominal contents back inside the wound using sterile gloves can lead to infection and is not within the nurse's scope of practice.