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If a client with increased pressure (ICP) demonstrates decorticate posturing, the nurse will observe:
- A. Flexion of both upper and lower extremities
- B. Extension of elbows and knees, plantar flexion of feet, and flexion of the wnsts
- C. Flexion of elbows, extension of the knees, and plantar flexion of the feet
- D. Extension of upper extremities, flexion of lower extremities
Correct Answer: B
Rationale: Decorticate posturing is characterized by flexion of elbows, wrists, and fingers; extension of elbows and knees; plantar flexion of the feet. This type of posturing typically indicates severe damage to the cerebral hemispheres or impairment of the corticospinal tract. When a client with increased intracranial pressure (ICP) displays decorticate posturing, it suggests significant brain injury and dysfunction. This abnormal posturing is a classic sign that requires immediate medical attention and intervention.
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How should the nurse prepare a suspension before administration?
- A. By diluting it with normal saline solution
- B. By diluting it with 5% dextrose solution
- C. By shaking it so that all the drug particles are dispersed uniformly
- D. By crushing remaining particles with a mortar and pestle
Correct Answer: C
Rationale: The correct way to prepare a suspension before administration is by shaking it so that all the drug particles are dispersed uniformly. Suspending agent particles settle over time, creating a layer of liquid at the top and a layer of solid at the bottom. By shaking the suspension, the nurse ensures that the drug particles are fully mixed and distributed evenly throughout the liquid. This step is crucial to ensure that the patient receives the correct dosage of the medication with each administration. Diluting the suspension with normal saline or dextrose solutions or crushing remaining particles with a mortar and pestle are not recommended methods for preparing a suspension before administration.
A child is to receive a blood transfusion, if an allergic reaction to the blood occurs, the nurse's first intervention should be:
- A. Relieved the symptoms with an ordered
- B. Slow the flow rate antihistamines
- C. Stop the blood immediately
Correct Answer: C
Rationale: In the scenario of a child experiencing an allergic reaction during a blood transfusion, the nurse's first intervention should always be to stop the blood immediately. This is crucial to prevent further complications and adverse reactions in the child. Pausing the transfusion allows for assessment of the allergic reaction's severity, immediate treatment initiation, and alerting the healthcare team for further management. Relieving symptoms with antihistamines or slowing the flow rate would not address the primary concern of stopping the allergen from entering the child's system. Therefore, stopping the blood immediately is the most appropriate and urgent action to take in this situation.
Which of the following is a nurse patient care role in the preoperative phase?
- A. Obtaining preoperative orders
- B. Offering emotional support
- C. Explaining the surgical procedure
- D. Providing informed consent
Correct Answer: A
Rationale: In the preoperative phase, one of the key roles of a nurse in patient care is to obtain preoperative orders. This involves ensuring that all necessary tests, medications, and procedures are in place before the surgery is performed. By obtaining preoperative orders, the nurse ensures that the patient is adequately prepared for the surgical procedure and that any potential risks or complications are minimized. This role requires attention to detail, clear communication with the healthcare team, and a thorough understanding of the patient's individual needs and medical history.
Assume you are going to estimate the prevalence of amoebic dysentery in a small country which harbors a total number of population of 530,000; you find that 57,000 of the population are infected by the disease. The prevalence of this disease is closest to
- A. 5.33%
- B. 7.45%
- C. 10.75%
- D. 20.22%
Correct Answer: C
Rationale: Prevalence = (Number of infected / Total population) * 100 = (57,000 / 530,000) * 100 ≈ 10.75%.
The nurse is preparing a parent of a newborn for home phototherapy. Which statement made by the parent would indicate a need for further teaching?
- A. "I should change the baby's position many times during the day."
- B. "I can dress the baby in lightweight clothing while under phototherapy."
- C. "I should be sure that the baby's eyelids are closed before applying patches."
- D. "I can take the patches off the baby during feedings and other caregiving activities."
Correct Answer: D
Rationale: The correct statement should be that the patches need to remain on the baby's eyes at all times during phototherapy. Removing the eye patches can potentially allow harmful light exposure to the eyes, which can lead to complications such as eye damage. It is essential for the parent to understand the importance of keeping the eye patches on to protect the baby's eyes during phototherapy. Therefore, further teaching is needed to emphasize the importance of leaving the eye patches on at all times, even during feedings and caregiving activities.