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An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:
- A. Has a sudden and severe increase in intracranial pressure
- B. Has sustained an internal injury in addition to the head injury
- C. Is beginning to experience a dangerously high level of anxiety
- D. Is having intracranial bleeding
Correct Answer: B
Rationale: Rising pulse rate and lowering blood pressure are indicative of hypovolemia, which is consistent with an internal injury causing blood loss.
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A patient is diagnosed with secondary syphilis. The nurse can expect the patient to have:
- A. Copper penny' rash on the palms of the hands and soles of the feet
- B. Localized tumors in the skin, bones, and liver
- C. Chancres and lymphadenopathy
- D. General paresis
Correct Answer: A
Rationale: Secondary syphilis presents with a maculopapular rash, often on the palms and soles, described as ‘copper penny’ lesions. Chancres occur in primary syphilis, tumors (gummas) in tertiary syphilis, and general paresis is a late neurosyphilis complication.
A client with a fractured femur is placed in skeletal traction. Which assessment finding requires immediate intervention?
- A. The client’s foot is cool to the touch.
- B. The client reports pain at the fracture site.
- C. The traction weights are resting on the floor.
- D. The client is performing active range of motion exercises.
Correct Answer: A
Rationale: A cool foot indicates potential vascular compromise, a serious complication in skeletal traction requiring immediate intervention to prevent tissue damage. Pain is expected, weights on the floor disrupt traction but are less urgent, and exercises are encouraged if appropriate.
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
- A. Blood pressure of 90/60 mmHg
- B. Weight gain of 2 pounds
- C. Serum sodium of 140 mEq/L
- D. Heart rate of 80 beats per minute
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
- A. Chorioamnionitis
- B. Preterm delivery
- C. Fetal distress
- D. All of the above
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
A client with pregnancy-induced hypertension is scheduled for a C-section. Before surgery, the nurse should keep the client:
- A. On her right side
- B. Supine with a small pillow
- C. On her left side
- D. In knee chest position
Correct Answer: C
Rationale: The left lateral position improves uteroplacental blood flow in pregnancy-induced hypertension, reducing fetal distress risk. Right-sided, supine, or knee-chest positions are less optimal.