Nokea
An adult is admitted with a head injury following an accident. He has a severe headache and asks the nurse why he cannot have something for pain. The nurse understands that the client should not receive a narcotic analgesic for which reason?
- A. Narcotic analgesics cause mydriasis, which will raise intracranial pressure.
- B. Narcotic analgesics are not effective for pain caused by brain trauma.
- C. Narcotic analgesics cause vomiting, which would mask a sign of increased intracranial pressure.
- D. Narcotic analgesics may depress respirations, which would cause acidosis and further brain damage.
Correct Answer: D
Rationale: Narcotics depress respirations, risking CO2 retention, acidosis, and increased intracranial pressure in head injury clients. Mydriasis, ineffectiveness, or vomiting are less critical concerns.
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The nurse is reinforcing teaching to the caregiver of a child diagnosed with ringworm on the abdomen. Which statement by the caregiver indicates a need for further teaching?
- A. Handwashing is very important as ringworm can be spread among humans and pets.
- B. I must apply antifungal cream to all affected areas to eradicate ringworm from the body.
- C. My child has been infected by a worm and must be treated to rid it from the body.
- D. My child may be uncomfortable due to itching, but this is not a dangerous condition.
Correct Answer: C
Rationale: Ringworm is a fungal infection, not a parasitic worm (C), indicating a misunderstanding requiring further teaching. Handwashing (A), antifungal cream (B), and recognizing itching as non-dangerous (D) are correct, reflecting proper understanding.
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
The nurse enters the room of a client who had major abdominal surgery 1 week ago and notes dehiscence and evisceration of the surgical incision. The nurse should immediately place the client in the
- A. Low Fowler position with the knees bent
- B. Prone position
- C. Supine position with the head of the bed flat
- D. Side-lying position
Correct Answer: A
Rationale: Low Fowler with knees bent (A) reduces abdominal tension, preventing further evisceration while awaiting surgical intervention. Prone (B), supine flat (C), or side-lying (D) increase strain or risk organ protrusion.
The office nurse receives 4 telephone messages from clients. Which client does the nurse anticipate as the priority for treatment?
- A. 20-year-old college student who reports a ringlike, red bull’s-eye-shaped, itchy leg rash after hiking in the woods 2 days ago
- B. 65-year-old female with pneumonia taking antibiotics who reports white, curdlike vaginal discharge and itching
- C. 78-year-old prescribed warfarin who reports increasing headaches and gait disturbance after falling a month ago
- D. 86-year-old with gout who is prescribed colchicine and reports diarrhea and not feeling well
Correct Answer: C
Rationale: Headaches and gait disturbance in a 78-year-old on warfarin post-fall (C) suggest a possible subdural hematoma, a life-threatening condition requiring immediate evaluation. Bull’s-eye rash (A) suggests Lyme disease, vaginal discharge (B) indicates yeast infection, and diarrhea (D) is a colchicine side effect, all less urgent.
The nurse is caring for a client who is experiencing hypotension and respiratory depression after administration of IV midazolam. The nurse should anticipate that the client will receive
- A. Acetylcysteine
- B. Benztropine
- C. Phentolamine
- D. Flumazenil
Correct Answer: D
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression and hypotension in overdose. Flumazenil (D) is the specific antidote, reversing benzodiazepine effects. Acetylcysteine (A) treats acetaminophen overdose, benztropine (B) manages extrapyramidal symptoms, and phentolamine (C) treats hypertensive crises, none of which apply here.