Nokea
If the nurse collects the following data, which assessment finding best indicates the presence of increased intracranial pressure?
- A. Rapid bilateral pupillary response to light
- B. Tympanic temperature of 97.9°F (36.6°C)
- C. Blood pressure of 150/90 mm Hg
- D. Deep tendon reflexes +2
Correct Answer: C
Rationale: Elevated blood pressure (e.g., 150/90 mm Hg) is a sign of increased intracranial pressure, often part of Cushing's triad (hypertension, bradycardia, irregular respirations), indicating brain compression.
You may also like to solve these questions
When preparing the adolescent for the examination, the nurse correctly explains that a specimen should be collected and sent to the laboratory. Which specimen should the nurse collect?
- A. Blood sample
- B. Urine sample
- C. Vaginal smear
- D. Biopsy of the cervix
Correct Answer: C
Rationale: A vaginal smear is appropriate for diagnosing gonorrhea in females, allowing culture or nucleic acid testing of cervical or vaginal secretions to detect Neisseria gonorrhoeae.
The nurse is caring for the client who has just given birth to a baby boy. The mother is O negative. The nurse should assess for ABO incompatibility and hyperbilirubinemia if the infant’s blood type is which type?
- A. O positive
- B. O negative
- C. A negative
- D. Any type
Correct Answer: C
Rationale: ABO incompatibility occurs when a mother with type O blood (no antigens A/B antibodies) has an infant with A or B blood (e.g. A negative) leading to hemolysis and hyperbilirubinemia. O blood types are compatible.
When caring for a child with measles, which precaution is most appropriate for the nurse to implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: D
Rationale: Measles is highly contagious and spreads via airborne transmission, requiring airborne precautions, including a negative-pressure room and N95 respirator use.
Which nursing instruction concerning ice applications is appropriate to give the parents of a 12-year-old child with a sprained ankle?
- A. Ice can be applied and left on until the swelling is gone.
- B. Ice can be applied but must be removed every 30 minutes to 1 hour to check the ankle.
- C. Ice should not be used for treating sprains; heat should be used instead.
- D. There is no danger associated with the application of ice.
Correct Answer: B
Rationale: Ice should be applied intermittently (e.g., 20-30 minutes on, then off) to prevent tissue damage and allow skin assessment, making removal every 30 minutes to 1 hour appropriate.
The pathological retraction ring of Bandl is associated with:
- A. Preterm labour.
- B. Obstructed labour.
- C. Precipitate labour.
- D. Abruptio placenta.
- E. Chorioamnionitis.
Correct Answer: B
Rationale: Bandl’s ring a pathological retraction ring forms in obstructed labor due to prolonged intense uterine contractions leading to a visible ridge between the upper and lower uterine segments.