Nokea
A nurse is collecting data from a school-age child who has sustained a skull fracture. Which of the following is a manifestation of increased intracranial pressure?
- A. Nausea
- B. Confusion about own name
- C. Rapid pulse
- D. Vomiting
Correct Answer: B
Rationale: Confusion, especially about one's own name, is a sign of increased intracranial pressure and should be addressed. Nausea and vomiting are common symptoms of increased intracranial pressure, but confusion about personal information is a more specific and critical indication that requires immediate attention. Rapid pulse may be a possible response to increased intracranial pressure, but it is not as specific as confusion about own name in this scenario.
You may also like to solve these questions
What are common risk factors for urinary tract infections (UTIs)?
- A. Poor hygiene and dehydration
- B. Increased sexual activity and pregnancy
- C. Use of urinary catheters and prolonged bed rest
- D. Family history and obesity
Correct Answer: A
Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.
What are the signs of hypoglycemia, and how should they be managed?
- A. Sweating, trembling; administer glucose
- B. Headache, confusion; administer insulin
- C. Dizziness, fatigue; administer glucose
- D. Increased heart rate; provide a high-sugar snack
Correct Answer: A
Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.
What is the priority when managing a client with a chest tube postoperatively?
- A. Clamp the chest tube for 30 minutes every 4 hours
- B. Check for air leaks and proper functioning of the chest tube
- C. Encourage deep breathing and coughing every 2 hours
- D. Encourage frequent coughing to clear secretions
Correct Answer: B
Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.
What are key signs of a urinary tract infection (UTI) in older adults?
- A. Confusion and increased temperature
- B. Painful urination and frequent urination
- C. Dizziness and headache
- D. Back pain and fever
Correct Answer: A
Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.
A client who is postoperative following a cholecystectomy has a urine output of 25 mL/hr. Which of the following findings should the nurse report to the provider?
- A. Abdominal pain radiating to the right shoulder.
- B. Absent bowel sounds.
- C. Brown drainage on the surgical dressing.
- D. Urine output of 25 mL/hr.
Correct Answer: D
Rationale: A urine output below 30 mL/hr indicates a potential complication, such as hypovolemia or renal impairment, and should be reported. Abdominal pain radiating to the right shoulder can be common after a cholecystectomy due to referred pain from the diaphragm, whereas absent bowel sounds may be expected temporarily postoperatively. Brown drainage on the surgical dressing is typical in the early postoperative period and may represent old blood or other normal discharge.