Nokea
A client with signs of increased intracranial pressure (ICP).
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
- A. Encourage coughing and deep breathing to prevent pneumonia.
- B. Suction the airway every 2 hours to remove secretions.
- C. Position the client in the prone position to promote venous return.
- D. Determine cough reflex and ability to swallow prior to administering PO fluids.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration
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A 4 lb 10 oz baby boy delivered at 32 weeks gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. He has mottling of the skin and acrocyanosis with irregular respirations of 60.
The nurse should recognize these findings as signs of
- A. hypoglycemia.
- B. cold stress.
- C. birth asphyxia.
- D. hypovolemia.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) blood sugar less than 25 mg/dL, would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma (2) correct-symptoms describe cold stress (3) would see meconium stained amniotic fluid (4) would see symptoms of shock
The nurse is caring for a client with a history of heart failure who is receiving digoxin 0.125 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Fatigue and weakness.
- B. Nausea and loss of appetite.
- C. Occasional palpitations.
- D. Mild ankle edema.
Correct Answer: B
Rationale: Nausea and loss of appetite suggest digoxin toxicity, a medical emergency. Options A, C, and D are less specific or expected in heart failure.
A woman comes to the antepartum clinic for a routine prenatal examination. She is 12 weeks pregnant with her second child. Which of the following shows proper documentation of the client's obstetric history by the nurse?
- A. Para 2, Gravida 1
- B. Nulligravida 2, Para 1
- C. Primigravida 1, Para 1
- D. Gravida 2, Para 1
Correct Answer: D
Rationale: Gravida 2, Para 1. Gravida describes a woman who is or has been pregnant, regardless of pregnancy outcome. Para describes the number of babies born past a point of viability.
The nurse is teaching a client with a new diagnosis of osteoarthritis about celecoxib (Celebrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any black, tarry stools
- C. Stop the medication if pain decreases
- D. Avoid regular joint exams
Correct Answer: B
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious celecoxib side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication may not be advised, and exams are needed.
The physician suggests play therapy for a 7-year-old girl who is having some difficulty adjusting to her parents' impending divorce. The nurse knows this type of therapy is useful because
- A. young children have difficulty verbalizing emotions.
- B. children hesitate to confide in anyone but their parents.
- C. play is an enjoyable form of therapy for children.
- D. play therapy is helpful in preventing regression.
Correct Answer: A
Rationale: children have difficulty putting feelings into words; play is how they express themselves