Nokea
A nurse is assessing a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
- A. Tachypnea
- B. Hypotension
- C. Decreased level of consciousness
- D. Bilateral weakness of extremities
Correct Answer: C
Rationale: Decreased LOC is the earliest and most sensitive sign of increased ICP.
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A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take?
- A. Tape the connections on the client's chest tube.
- B. Position the client in a supine position.
- C. Strip the client's chest tube every 2 hours.
- D. Place the chest tube drainage system above the level of the client's heart.
Correct Answer: A
Rationale: Taping connections maintains a closed system and prevents air leaks that could cause pneumothorax.
The healthcare provider has determined that a client has contracted hepatitis A based on flu-like symptoms and jaundice. Which statement made by the client supports this medical diagnosis?
- A. I was an intravenous drug abuser in the past and shared needles.
- B. I ate shellfish about 2 weeks ago at a local restaurant.
- C. I had a blood transfusion 30 years ago after major abdominal surgery.
- D. I have had unprotected sex with multiple partners.
Correct Answer: B
Rationale: Hepatitis A is typically transmitted through contaminated food/water - shellfish is a known source.
A client with advanced cirrhosis has been admitted to the medical-surgical unit. The nurse is assessing the client and identifies which of the following findings as indicators of hepatic encephalopathy? (Select all that apply).
- A. Asterixis
- B. Change in orientation
- C. Anorexia
- D. Ascites
- E. Fetor hepaticus
Correct Answer: A,B,E
Rationale: These are signs of hepatic encephalopathy reflecting cerebral effects of ammonia toxicity.
A nurse in an emergency department is planning care for a client who is having an acute myocardial infarction (MI). Which of the following medications should the nurse plan to administer after the initial acute phase to manage the client's pain and anxiety?
- A. Nitroglycerin
- B. Aspirin
- C. Oxygen
- D. Morphine
Correct Answer: D
Rationale: Morphine is used for pain/anxiety management post-MI after acute interventions.
A client in the emergency department has suspected stomach perforation due to a peptic ulcer. The nurse is completing the assessment and should expect which of the following findings? (Select all that apply).
- A. Tachycardia
- B. Rebound tenderness
- C. Rigid abdomen
- D. Elevated blood pressure
Correct Answer: A,B,C
Rationale: These are classic signs of perforation and peritonitis: tachycardia from pain/stress, rebound tenderness and rigidity from peritoneal irritation.