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An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
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The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction. Toe movement, sharp/dull, and Babinski reflex test other functions.
The client's eyes, tested with the use of a Snellen chart, show 20/40 vision in the right eye and 20/30 in the left eye. How should the nurse interpret these results?
- A. The client has elevated intraocular pressure in both eyes.
- B. The client needs testing for glaucoma with a tonometer.
- C. The left eye is closer to normal vision than the right eye.
- D. The client has errors of refraction indicating astigmatism.
Correct Answer: C
Rationale: The Snellen chart is used to test distance vision. The numbers recorded indicate that at 20 feet (the first number) the client is able to read what a person with normal vision can read at another distance (second number). The left eye's vision recorded as 20/30 has better vision than the right eye with vision recorded as 20/40. The Snellen chart is not used to measure intraocular pressure, suggest glaucoma testing, or determine astigmatism.
The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.
A resident of a long-term care facility tells the nurse, 'I'm having a hard time hearing people talk and can't understand the voices on TV.' Which action is most appropriate?
- A. Teach the client about eliminating background noises in the room.
- B. Assess the client's hearing and use an otoscope for examination.
- C. Schedule an appointment with the HCP for bilateral ear irrigations.
- D. Instruct the client to look at the speaker's lips to decipher words.
Correct Answer: B
Rationale: The nurse should assess the client's hearing and perform an otoscopic examination to verify symptoms and identify the cause. Other actions follow assessment.
The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
- A. Ensure that all room walls are painted with colors that blend.
- B. Use a white board and a black marker when writing out lists.
- C. Place Velcro tabs on wall light switches to ease locating them.
- D. Ensure that doorknobs on the doors are a bright contrasting color.
- E. Match the color of dishes with the color of table-cloths or placemats.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.