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A nurse is collecting data from a client who has a subdural hematoma following a motor-vehicle crash. For which of the following findings should the nurse identify that the client is experiencing an increase in intracranial pressure?
- A. The client has a delayed response to verbal commands.
- B. The client has ecchymosis around the eyes.
- C. The client is unable to remember details of the motor-vehicle crash.
- D. The client reports ringing in the ears.
Correct Answer: A
Rationale: Delayed verbal response indicates rising intracranial pressure (ICP) affecting brain function. Ecchymosis and amnesia are hematoma signs, and ringing ears isn't specific to ICP.
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A nurse is assisting in the care of the client who is postoperative following a fasciotomy. Which of the following actions should the nurse take?
- A. Prepare to administer an antibiotic.
- B. Administer an analgesic.
- C. Restrict fluid intake.
- D. Prepare to obtain a wound culture.
- E. Initiate supplemental oxygen.
Correct Answer: B
Rationale: Post-fasciotomy, pain from surgical incision and prior compartment pressure is expected, making analgesia a priority to enhance comfort and mobility, aiding recovery. Antibiotics are proactive for infection, but no fever or purulent drainage (Exhibit) justifies immediate use prophylaxis may apply, not routine post-op. Fluid restriction contradicts hydration needs for healing and circulation, especially with serosanguinous drainage. Wound cultures are indicated for infection signs (e.g., redness, pus), not routine here with a dry, intact dressing. Pain management aligns with postoperative care principles unrelieved pain increases stress, delays ambulation, and risks chronicity making analgesic administration the most immediate, evidence-based action to support the client's well-being and surgical outcome.
A nurse is preparing to perform a blood glucose test. After performing hand hygiene and donning gloves, in which order should the nurse perform the following actions to obtain a capillary blood sample?
- A. Allow the site to dry.
- B. Pierce the puncture site quickly.
- C. Squeeze the site gently to obtain a blood droplet.
- D. Cleanse the site with an antiseptic swab.
- E. Apply blood to the test strip.
Correct Answer: D,A,B,C,E
Rationale: The order is: Cleanse with antiseptic (D), allow to dry (A), pierce (B), squeeze for blood (C), and apply to strip (E) for an accurate, sterile sample.
A nurse is collecting data from an older adult client who has cystitis. Which of the following findings should the nurse anticipate?
- A. Confusion
- B. Hypothermia
- C. Referred pain in the right shoulder
- D. Orange colored urine
- E. Fever
- F. Dysuria
- G. Urgency
Correct Answer: A
Rationale: Confusion is common in older adults with cystitis due to altered mental status from infection.
A nurse in a health clinic is collecting data from an older adult client. Which of the following information in the client's history increases her risk for osteoporosis?
- A. The client is a gardener.
- B. The client is lactose intolerant.
- C. The client has a glass of red wine every evening
- D. The client walks 3.2 km (2 mi) daily.
- E. The client smokes daily.
- F. The client has a family history of osteoporosis.
- G. The client takes corticosteroids long-term.
Correct Answer: B
Rationale: Lactose intolerance limits calcium intake, a key risk factor for osteoporosis; gardening and walking are protective, and moderate wine has minimal impact.
A nurse is assisting in the care of the client who has iron deficiency anemia. Which of the following statements indicate the client understands the instructions?
- A. I should increase green leafy vegetables in my diet.
- B. The iron supplement might cause my stools to be black.
- C. I should expect to have swelling in my feet.
- D. I will take my iron supplement 1 hour before a meal.
Correct Answer: B
Rationale: Iron supplements oxidize in the gut, often turning stools black due to unabsorbed iron a normal, expected effect clients should recognize to avoid alarm. Green leafy vegetables (e.g., spinach) boost dietary iron, but oxalates limit absorption, making this less indicative of supplement-specific teaching. Swelling in feet isn't a typical iron effect edema suggests heart or kidney issues, not anemia treatment. Taking iron 1 hour before meals aids absorption, a good practice, but the question emphasizes understanding therapy outcomes. Black stools confirm the client grasps a common, visible side effect, aligning with education goals (e.g., managing expectations), ensuring adherence and reducing unnecessary worry, making it the clearest sign of comprehension.