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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 Cushings 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 shallow respirations
- D. Hypotension
Correct Answer: A
Rationale: The correct answer is A: Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg. Cushing's triad is a classic sign of increased intracranial pressure (ICP), seen in traumatic brain injury. It consists of hypertension (elevated blood pressure), bradycardia (not tachycardia), and irregular respirations (not rapid shallow respirations). The increase in blood pressure is due to the body's attempt to maintain cerebral perfusion in response to the increased ICP. The other choices are incorrect because they do not align with the classic presentation of Cushing's triad in traumatic brain injury.
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A nurse is assessing a client who is undergoing radiation therapy for breast cancer. Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the therapy?
- A. Skin changes
- B. Hypertension
- C. Diarrhea
- D. Increased white blood cell count
Correct Answer: A
Rationale: The correct answer is A: Skin changes. This is because skin changes, such as redness, irritation, or peeling, are common adverse effects of radiation therapy. The skin over the treated area may become sensitive and may develop a sunburn-like appearance. This indicates that the radiation is affecting the skin cells. Hypertension (B), diarrhea (C), and increased white blood cell count (D) are not typically associated with adverse effects of radiation therapy for breast cancer. Hypertension may be related to stress or other factors, diarrhea could be due to other causes, and an increased white blood cell count is not a typical adverse effect of radiation therapy.
A nurse is inspecting the skin of a client who has basal cell carcinoma. The nurse should identify which of the following lesion characteristics on the clients skin?
- A. A pearly, waxy nodule
- B. A scaly, red patch
- C. A dark, irregular mole
- D. A firm, painless lump
Correct Answer: A
Rationale: The correct answer is A: A pearly, waxy nodule. Basal cell carcinoma typically presents as a pearly, waxy nodule on the skin. This characteristic appearance is due to the growth of abnormal cells in the basal cell layer of the skin. The nodule may also have small blood vessels visible on its surface. This presentation is distinct from other skin lesions. Choice B, a scaly red patch, is more indicative of conditions like psoriasis or eczema. Choice C, a dark irregular mole, is more suggestive of melanoma. Choice D, a firm, painless lump, is more characteristic of conditions like lipomas or fibromas. Thus, the correct answer is A based on the specific characteristics of basal cell carcinoma.
A home health nurse is assisting a client with planning care for a family member who has Alzheimers disease. Which of the following instructions should the nurse include?
- A. Review the daily schedule with the client every morning.
- B. Limit the clients fluid intake to prevent accidents.
- C. Encourage the client to engage in complex tasks.
- D. Restrict the clients social interactions to reduce confusion.
Correct Answer: A
Rationale: The correct answer is A: Review the daily schedule with the client every morning. This instruction is important for individuals with Alzheimer's disease as it helps provide structure and routine, which can help reduce confusion and anxiety. By reviewing the daily schedule, the client can be prepared for the day's activities, promoting a sense of familiarity and independence.
Option B is incorrect because limiting fluid intake can lead to dehydration and other health issues. Option C is incorrect as individuals with Alzheimer's disease may struggle with complex tasks and may become frustrated. Option D is incorrect because social interactions are important for mental stimulation and emotional well-being, restricting them can lead to increased confusion and isolation.
A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
- A. Flattened T waves
- B. Peaked T waves
- C. Prolonged PR interval
- D. ST segment depression
Correct Answer: B
Rationale: The correct answer is B: Peaked T waves. In hyperkalemia (high potassium level), the myocardium becomes more excitable, leading to changes in the ECG. Peaked T waves are a classic sign of hyperkalemia, indicating early stages of cardiac involvement. Flattened T waves (choice A) are associated with hypokalemia. Prolonged PR interval (choice C) and ST segment depression (choice D) are not typically seen in hyperkalemia.
A nurse is caring for a client who is intubated and receiving mechanical ventilation for heroin toxicity. Which of the following assessments is the nurses priority?
- A. Monitor urine output.
- B. Assess level of consciousness.
- C. Check ABGs.
- D. Monitor for signs of withdrawal.
Correct Answer: C
Rationale: The correct answer is C: Check ABGs. In this scenario, monitoring the client's arterial blood gases (ABGs) is the priority assessment because heroin toxicity can lead to respiratory depression and impaired gas exchange. ABGs provide crucial information about the client's oxygenation and ventilation status, which is essential for managing mechanical ventilation and preventing respiratory complications. Monitoring urine output (A) is important but not the priority in a client with potential respiratory compromise. Assessing level of consciousness (B) is significant, but ensuring adequate oxygenation takes precedence. Monitoring for signs of withdrawal (D) is important but not as urgent as assessing respiratory status.