Nokea
A nurse is assessing a 18 year-old female who has recently suffered a TBI. The nurse should report these findings immediately to the physician, due to the possibility the patient is experiencing which of the following conditions?
- A. Increased intracranial pressure
- B. Increased function of cranial nerve X
- C. Sympathetic response to activity
- D. Meningitis
Correct Answer: A
Rationale: The patient is at high risk of developing increased intracranial pressure (ICP) due to the traumatic brain injury, which can cause a slower pulse and impaired respiration.
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The focus of a nurse case manager is:
- A. nursing care needs at discharge.
- B. the comprehensive care needs of the client for continuity of care.
- C. client education needs upon discharge.
- D. financial resources for needed care.
Correct Answer: B
Rationale: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.
A nurse assesses a 83 year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?
- A. Encourage warm water soaks to the right foot.
- B. Notify the case manager of the purulent drainage.
- C. Determine the patient's pulse in the right ankle.
- D. Recommend increased activity to reduce the purulent drainage.
Correct Answer: A
Rationale: A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.
Pulling is easier than pushing. So pulling a client rather than pushing him or her has which of the following advantages?
- A. Reduces workload
- B. Decreases opposition from gravity
- C. Maintains stability
- D. Prevents muscle strain
Correct Answer: A
Rationale: Pulling reduces workload by working with gravity, lowering the effort needed compared to pushing against it.
The hydraulic lift (Hoyer lift) is:
- A. used for all clients who've had orthopedic surgery.
- B. used for all clients who are not able to stand and for extremely obese clients.
- C. used for all clients, both old and young, in a hospital setting.
- D. not an assistive device for special needs.
Correct Answer: B
Rationale: The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.
Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing's advocacy for clients.
- C. confidentiality.
- D. health care.
Correct Answer: B
Rationale: Advocacy for clients by nurses is the primary focus of the client's right to autonomy and self-determination. Confidentiality involves the maintenance of the privacy of the client and information regarding him or her. Malpractice insurance is a type of insurance for professionals.