Nokea
Increased intracranial pressure can cause which of the following?
- A. seizure
- B. nausea
- C. vomiting
- D. all of the above
Correct Answer: D
Rationale: Increased intracranial pressure (ICP) can cause a variety of symptoms, including seizures, nausea, and vomiting. When the pressure inside the skull rises, it can put pressure on the brain tissue, leading to changes in normal brain function. Seizures may occur as a result of the altered brain activity. Nausea and vomiting can also be triggered by increased ICP, as the body's natural response to the disturbance in the brain's normal functioning. Therefore, all of the listed options (seizure, nausea, vomiting) can be caused by increased intracranial pressure.
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The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?
- A. Cardiac arrhythmia
- B. Hypostatic pneumonia
- C. Heart failure
- D. Rapidly increasing blood pressure
Correct Answer: A
Rationale: After a cardiac catheterization, the nurse should be assessing for the development of cardiac arrhythmias, as this is a potential complication associated with the procedure. Cardiac arrhythmias can occur due to irritation of the heart during the catheterization, changes in electrolyte levels, or other factors related to the procedure. Monitoring the child's cardiac rhythm closely allows for early detection and management of arrhythmias to prevent serious complications. While other complications such as hypostatic pneumonia, heart failure, and rapidly increasing blood pressure can also occur, cardiac arrhythmia is the most important complication to assess for immediately post-cardiac catheterization.
A client with primary diabetes insipidus is ready for discharge on desmopressin (DDAVP). Which instruction should the nurse provide?
- A. "Administer desmopressin while the suspension is cold."
- B. "Your condition isn't chronic, so you won't need to wear a medical identification bracelet."
- C. "You may not be able to use desmopressin nasally if you have nasal discharge or blockage."
- D. "You won't need to monitor your fluid intake and output after you start taking desmopressin."
Correct Answer: C
Rationale: It is important for the nurse to instruct the client that they may not be able to use desmopressin nasally if they have nasal discharge or blockage. This is because nasal absorption is critical for the effectiveness of desmopressin, and any nasal issues may hinder proper absorption. If the client experiences nasal discharge or blockage, an alternative route for administering desmopressin may need to be considered, such as oral or injectable forms. This instruction is essential to ensure the client receives the medication effectively and manages their condition appropriately.
While bathing an 82 y.o. man hospitalized with pneumonia, a nurse notes an ulcerated area on his penis. What action should the nurse take first?
- A. Report the ulcer to the admitting care provider.
- B. Teach the man about STD prevention.
- C. Ask the man if he has a history of syphilis.
- D. Clean the ulcer; reporting is not necessary because an STD is unlikely in a man this age.
Correct Answer: A
Rationale: The nurse should report the ulcer to the admitting care provider as the first action. An ulcerated area on the penis in an older adult may be indicative of various serious conditions, such as sexually transmitted infections (STIs) or skin breakdown. It is important for the healthcare provider to assess the ulcer, determine the cause, and initiate appropriate treatment. Reporting the finding promptly ensures timely intervention and appropriate management of the patient's condition. This initial action takes priority over teaching about STD prevention or inquiring about the patient's history of syphilis. Cleaning the ulcer without proper assessment and diagnosis by a healthcare provider can potentially worsen the patient's condition.
The child who can transfers object from hand to hand and babbles has achieved the developmental age of
- A. 4 months
- B. 6 months
- C. 8 months
- D. 10 months
Correct Answer: B
Rationale: Transferring objects and babbling typically occur around 6 months.
Baby Melody is a neonate who has a very low-birth-weight. Nurse Josie carefully monitors inspiratory pressure and oxygen (O ) concentration to prevent which of the following?
- A. Meconium aspiration syndrome
- B. Bronchopulmonary dysplasia (BPD)
- C. Respiratory syncytial virus (RSV)
- D. Respiratory distress syndrome (RDS)
Correct Answer: D
Rationale: A neonate with very low birth weight is at risk of developing respiratory distress syndrome (RDS), which is a common breathing disorder in premature infants. RDS occurs due to a lack of a substance in the lungs called surfactant, which helps keep the air sacs open and prevents them from collapsing. In neonates with very low birth weight, the lungs may not have produced enough surfactant, leading to breathing difficulties and respiratory distress.