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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 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing?
- A. Has your ability to perceive colors changed?
- B. Does your vision appear distorted or wavy?
- C. Does the center of your visual field appear dark?
- D. Do you see random flashes of bright light?
Correct Answer: A
Rationale: Asking about a change in the ability to perceive colors will help in determining cataract development. Cataract formation involves the lens of the eye becoming more opaque, thus decreasing the vibrancy of colors. Distorted central vision is a sign of macular degeneration. A darkened area in the center of the visual field is associated with macular degeneration. Seeing flashes of bright lights is associated with retinal detachment.
The client is receiving treatment with gentamicin ophthalmic solution for bacterial conjunctivitis. Which symptom, described by the client, indicates that the medication is ineffective?
- A. Eyes feel strained
- B. Yellowish eye drainage
- C. Twitching of the eye
- D. Unable to read small print
Correct Answer: B
Rationale: Mucopurulent eye drainage, especially yellowish or greenish, is associated with bacterial conjunctivitis; continuing with eye drainage indicates gentamicin is ineffective in treating the infection. Eyestrain, twitching, and inability to read small print are not associated with an infectious process.
The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
- A. Varicella vaccine
- B. Pneumococcal vaccine
- C. Typhoid vaccine
- D. Zoster vaccine
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.
What should the nurse include when teaching the client with Parkinson's disease?
- A. He should try to continue working as long as he can remain sitting most of the day.
- B. Drooling may be reduced somewhat if he remembers to swallow frequently.
- C. He should return monthly for lab tests, which will predict the progression of the disease.
- D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson's disease.
Correct Answer: B
Rationale: Frequent swallowing can reduce drooling, a common symptom in Parkinson's disease, improving comfort and social interaction.
The nurse is providing teaching on the home treatment of acute sinusitis. Which interventions should the nurse advise the client to implement? Select all that apply.
- A. Take over-the-counter ranitidine.
- B. Apply warm compresses to the face.
- C. Use saline nasal spray as directed.
- D. Take over-the-counter pseudoephedrine.
- E. Spend time outdoors in the sunlight.
Correct Answer: B,C,D
Rationale: Applying warm compresses, using saline nasal spray, and taking a decongestant like pseudoephedrine relieve nasal and sinus congestion. Ranitidine treats dyspepsia, and sunlight exposure is unrelated to sinusitis.