Nokea
A nurse is assessing a client who has increased intracranial pressure. The nurse should recognize that which of the following is the first sign of deteriorating neurological status?
- A. Altered level of consciousness
- B. Cheyne-Stokes respirations
- C. Decorticate posturing
- D. Pupillary dilation
Correct Answer: A
Rationale: The correct answer is A: Altered level of consciousness. This is the first sign of deteriorating neurological status in a client with increased intracranial pressure. Changes in consciousness indicate impairment in brain function, signaling potential brain injury or worsening condition. Altered level of consciousness can progress rapidly if not addressed promptly.
Choice B, Cheyne-Stokes respirations, is associated with abnormal breathing patterns and typically occurs in conditions like heart failure or brain injury, but it is not the first sign of neurological deterioration.
Choice C, Decorticate posturing, is a sign of brain injury but typically occurs after alterations in consciousness.
Choice D, pupillary dilation, can be a sign of increased intracranial pressure, but it usually occurs after alterations in consciousness.
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A nurse is caring for a client who is postoperative and develops respiratory depression after receiving morphine for pain control. Which of the following medications should the nurse expect the provider to prescribe?
- A. Flumazenil
- B. Calcium gluconate
- C. Diphenhydramine
- D. Naloxone
Correct Answer: D
Rationale: The correct answer is D: Naloxone. Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. Therefore, the nurse should expect the provider to prescribe naloxone to counteract the respiratory depression caused by morphine. Flumazenil (A) is a benzodiazepine antagonist and would not be effective in this situation. Calcium gluconate (B) is used to treat calcium deficiencies and would not address respiratory depression. Diphenhydramine (C) is an antihistamine and not indicated for reversing opioid-induced respiratory depression.
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and has a referral for dietary consult. The client tells the nurse, 'I will have to eat whatever the dietitian tells me.' Which of the following statements by the nurse encourages the client's involvement in their plan of care?
- A. The dietitian will provide you with the best food choices to manage your diabetes.'
- B. I understand that the dietary choices can seem overwhelming.'
- C. I can assist you with making a list of foods you like for the dietitian.'
- D. Managing your diabetes will require you to make accommodations.'
Correct Answer: C
Rationale: The correct answer is C because it encourages the client's involvement in their plan of care by actively engaging them in the decision-making process. By offering to assist the client in making a list of foods they like for the dietitian, the nurse is promoting client autonomy and empowerment. This approach helps the client feel more in control of their dietary choices and encourages collaboration between the client, nurse, and dietitian.
Choice A is incorrect as it does not actively involve the client in decision-making. Choice B acknowledges the client's feelings but does not directly engage them in the process. Choice D focuses on the client's responsibilities but does not promote active participation.
A nurse is monitoring a client who has a traumatic brain injury. Which of the following findings should the nurse identify as a manifestation of Cushing's triad?
- A. Increase in blood pressure from 130/80 mm Hg to 180/100 mm Hg
- B. Decrease in heart rate to 120 bpm
- C. Rapid
- D. shallow respirations
- E. Hypotension
Correct Answer: A
Rationale: The correct answer is A because Cushing's triad consists of hypertension, bradycardia, and irregular respirations. In a client with a traumatic brain injury, increased intracranial pressure can lead to Cushing's triad due to brainstem compression. Option A reflects an increase in blood pressure, which is a key component of Cushing's triad. Choices B, C, and D do not align with the expected findings of Cushing's triad. Choice B indicates a decrease in heart rate, which is contrary to the bradycardia seen in Cushing's triad. Choice C mentions rapid respirations, whereas irregular or shallow respirations are more characteristic. Choice E mentions hypotension, which is not part of Cushing's triad. Therefore, option A is the correct choice as it aligns with the manifestation of hypertension in Cushing's triad.
A nurse is admitting a client who reports tightness in their chest that radiates to left arm. Which of the following findings require immediate follow-up?
- A. Temperature 37.1° C (98.8° F)
- B. Heart rate 110/min and irregular
- C. Respiratory rate 24/min
- D. Blood pressure 164/80 mm Hg
- E. Oxygen saturation 93% on room air
Correct Answer: B
Rationale: The correct answer is B: Heart rate 110/min and irregular. This finding suggests cardiac distress or arrhythmia, which could indicate a heart attack. Immediate follow-up is necessary to assess the client's cardiac status and intervene promptly.
Incorrect choices:
A: Temperature within normal range.
C: Respiratory rate within normal range.
D: Blood pressure slightly elevated but not an immediate concern.
E: Oxygen saturation slightly low but not critically low.
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
- A. Adventitious breath sounds
- B. Respiratory rate of 24/min
- C. Weight loss of 1.8 kg (4 lb) in the past 24 hr
- D. Elevation in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Weight loss of 1.8 kg (4 lb) in the past 24 hr. Furosemide is a diuretic that helps to reduce fluid retention, so weight loss indicates the medication is effectively reducing pulmonary edema. Adventitious breath sounds indicate respiratory issues, not medication effectiveness. A respiratory rate of 24/min could be within normal range and not necessarily indicative of medication effectiveness. Elevation in blood pressure could indicate a potential adverse effect of furosemide, not effectiveness. Weight loss is the most direct indicator of reduced fluid volume due to diuresis.