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A young adult who was in a motorcycle accident is brought to the emergency room with a closed head injury with suspected subdural hematoma.
- A. Which order should the nurse question for a young adult with a closed head injury and suspected subdural hematoma?
- B. Promethazine (Phenergan) 25 mg IM q3h.
- C. Morphine sulfate 10 mg IM q3-4h.
- D. Docusate sodium (Colace) 50 mg PO bid.
- E. Ranitidine (Zantac) 50 mg IVPB q12h.
Correct Answer: B
Rationale: Morphine sulfate, a narcotic analgesic, causes CNS and respiratory depression, which is contraindicated in head injuries because it masks signs of increased intracranial pressure, such as altered consciousness or pupil changes. Promethazine is an antiemetic, docusate is a stool softener, and ranitidine prevents stress ulcers, none of which pose the same risk.
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An adult client who has a fractured tibia is ordered to take one baby aspirin a day. He says to the nurse, 'I don't think the aspirin is doing any good. I still have pain.' What should the nurse include when replying to this client?
- A. The aspirin is given to prevent clots from forming.'
- B. The aspirin is given to keep your temperature normal.'
- C. The aspirin is given to control your pain and should be helping.'
- D. The aspirin is given to decrease inflammation at the fracture site.'
Correct Answer: A
Rationale: Low-dose aspirin is used to prevent thrombus formation in immobilized clients with fractures. It's not primarily for fever, pain, or inflammation in this context.
The home health nurse visits a client who is six-weeks postpartum.
- A. Which symptom reported by a six-week postpartum client warrants immediate follow-up?
- B. Occasional hot flashes.
- C. A pinkish vaginal discharge.
- D. Painful sexual intercourse.
- E. Feelings of fatigue.
Correct Answer: C
Rationale: Painful sexual intercourse six weeks postpartum is abnormal and may indicate infection, episiotomy complications, or other issues requiring immediate evaluation. Hot flashes, pinkish discharge, and fatigue are common during the postpartum period as the body recovers.
The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.
A client with an obsessive-compulsive ritual.
The nurse recognizes that the client with an obsessive-compulsive ritual is attempting to
- A. control other people.
- B. increase self-esteem.
- C. avoid severe levels of anxiety.
- D. express and manage anxiety.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate (2) inaccurate (3) correct-obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase his self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so (4) ritual is not a method of expressing anxiety, but a strategy to avoid it
Which contraindication should the nurse assess for prior to giving a child immunizations?
- A. Mild cold symptoms
- B. Chronic asthma
- C. Depressed immune system
- D. Allergy to eggs
Correct Answer: C
Rationale: Depressed immune system. Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.