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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A nurse is assigned to do pre-operative teaching on a blind patient who is scheduled for surgery the following morning. What teaching strategy would best fit the situation?
- A. Verbal teaching in short sessions throughout the day.
- B. Pre-operative booklet on the surgery in Braille.
- C. Provide a tape for the client.
- D. Have the blind patient's family member instruct the patient.
Correct Answer: A
Rationale: Information is smaller amounts is easier to retain. Teaching the day before the procedure is best accomplished in a one on one format.
Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually means the prognosis is less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be stopped.
Correct Answer: C
Rationale: The goal of palliative care is to make the client as comfortable as possible and not require a hospital stay. Prognoses vary and curative treatments can still be pursued during palliative care.
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
The client uses a walker to ambulate with partial weight-bearing after foot surgery. What should the nurse observe when this client is using the walker correctly?
- A. Has elbows bent at a 30-degree angle
- B. Is bent over the front bar of the walker
- C. While walking, lifts the walker 2 inches
- D. Has a walker that has four wheels in place
Correct Answer: A
Rationale: A: Elbows at 30 degrees indicate proper walker height. B: Bending over risks poor posture and falls. C: Lifting the walker prevents partial weight-bearing. D: Four-wheeled walkers are unsuitable for partial weight-bearing.
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.