Nokea
A three-month-old patient is experiencing increased intracranial pressure (ICP). Which of the following assessment findings should the nurse report to the physician?
- A. Pinpoint pupils.
- B. High-pitched cry.
- C. Decrease in blood pressure.
- D. Absence of reflexes.
Correct Answer: B
Rationale: sign of increased intracranial pressure
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A patient received meperidine (Demerol) 75 mg IM 2 hours ago for complaints of pain. The patient turns on his call light and tells the nurse he has to go to the bathroom. The physician has ordered BPR (bathroom privileges). The nurse should
- A. obtain a bedside commode for the patient's use and provide privacy.
- B. help the patient to sit on the side of the bed before proceeding to the bathroom.
- C. provide a bedpan for the patient's use and pull the curtains.
- D. get another nurse and together assist the client to the bathroom.
Correct Answer: B
Rationale: side effects of medication include decreased BP, orthostatic hypotension, bradycardia
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
- A. Absence of bowel sounds.
- B. Temperature of 99.8°F (37.7°C).
- C. Pain at the incision site.
- D. Urine output of 30 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
The nurse plans care for a 25-year-old woman immediately after a cesarean section. Which of the following nursing goals is MOST important?
- A. Prevent infection.
- B. Prevent fluid and electrolyte imbalances.
- C. Provide for pain management.
- D. Prevent hazards of immobility.
Correct Answer: B
Rationale: hemorrhage and shock most life-threatening conditions that occur after surgery
The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation