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A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A because Cushing's triad consists of hypertension, bradycardia, and irregular respirations. In a client with a traumatic brain injury, increased intracranial pressure can lead to Cushing's triad due to brainstem compression. Option A reflects an increase in blood pressure, which is a key component of Cushing's triad. Choices B, C, and D do not align with the expected findings of Cushing's triad. Choice B indicates a decrease in heart rate, which is contrary to the bradycardia seen in Cushing's triad. Choice C mentions rapid respirations, whereas irregular or shallow respirations are more characteristic. Choice E mentions hypotension, which is not part of Cushing's triad. Therefore, option A is the correct choice as it aligns with the manifestation of hypertension in Cushing's triad.
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Which findings indicate the client's condition has improved? (Select all that apply)
- A. Pain level
- B. Respiratory rate
- C. Heart rate
- D. Blood pressure
- E. Echocardiogram results
- F. Urinary Output
- G. Oxygenation Saturation
Correct Answer: A, B
Rationale: The correct answers are A and B. Pain level indicates the client's subjective improvement, while respiratory rate reflects their physiological status. Pain reduction suggests improved comfort and possibly better overall health, while a decrease in respiratory rate may indicate improved oxygenation and reduced stress. Choices C, D, E, F, and G are not directly linked to the client's overall condition improvement as they can vary for several reasons, independent of the client's actual health status.
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform strength-building arm exercises using a 15-pound weight.'
- B. I should expect less than 25 mL of secretions per day in the drainage devices.'
- C. I will have to wait 2 months before additional saline can be added to my breast expander.'
- D. I will keep my left arm flexed at the elbow as much as possible.'
Correct Answer: B
Rationale: The correct answer is B: "I should expect less than 25 mL of secretions per day in the drainage devices." This demonstrates an understanding of the need to monitor drainage postoperatively. Excessive drainage can indicate complications like infection or bleeding.
A: Performing strength-building exercises with a 15-pound weight is contraindicated postoperatively as it can strain the surgical site.
C: Waiting 2 months before adding saline to the expander is incorrect. Saline can be added gradually postoperatively.
D: Keeping the left arm flexed at the elbow is not recommended as it can lead to stiffness and limited range of motion.
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
- A. Adventitious breath sounds
- B. Respiratory rate of 24/min
- C. Weight loss of 1.8 kg (4 lb) in the past 24 hr
- D. Elevation in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Weight loss of 1.8 kg (4 lb) in the past 24 hr. Furosemide is a diuretic that helps to reduce fluid retention, so weight loss indicates the medication is effectively reducing pulmonary edema. Adventitious breath sounds indicate respiratory issues, not medication effectiveness. A respiratory rate of 24/min could be within normal range and not necessarily indicative of medication effectiveness. Elevation in blood pressure could indicate a potential adverse effect of furosemide, not effectiveness. Weight loss is the most direct indicator of reduced fluid volume due to diuresis.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
- A. Lower the client to the floor.
- B. Obtain the client's vital signs.
- C. Loosen the client's restrictive clothing.
- D. Clear items from the client's surrounding are
Correct Answer: D
Rationale: The correct action to take first when caring for a client experiencing a seizure is to clear items from the client's surrounding area (Choice D). This is important to prevent injury to the client during the seizure. By removing objects that could cause harm, such as sharp or hard items, the nurse ensures a safe environment for the client. Lowering the client to the floor (Choice A) is important but should be done after clearing the surroundings to prevent injury. Obtaining vital signs (Choice B) and loosening restrictive clothing (Choice C) can be done after ensuring the safety of the environment. Thus, the priority is to clear items from the client's surrounding area to prevent harm during the seizure.
A nurse is planning care for a client who is 12 hr postoperative following a kidney transplant. Which of the following actions should the nurse include in the plan of care?
- A. Check the client's blood pressure every 8 hr.
- B. Assess urine output hourly.
- C. Administer opioids PO.
- D. Monitor for hypokalemia as a manifestation of acute rejection.
Correct Answer: B
Rationale: The correct answer is B: Assess urine output hourly. This is important postoperatively to monitor kidney function and ensure adequate perfusion. Hourly assessment allows for early detection of any changes in urine output, which can indicate complications such as acute kidney injury. Checking blood pressure every 8 hours (Choice A) may be necessary but is less critical in the immediate postoperative period. Administering opioids PO (Choice C) can mask changes in the client's condition and should be avoided until kidney function is stable. Monitoring for hypokalemia (Choice D) is important but not the priority in the immediate postoperative period.