Nokea
The client is admitted to the unit after a motor vehicle accident with a temperature of 102°F rectally. The most likely explanations for the elevated temperature is that:
- A. There was damage to the hypothalamus.
- B. He has an infection from the abrasions to the head and face.
- C. He will require a cooling blanket to decrease the temperature.
- D. There was damage to the frontal lobe of the brain.
Correct Answer: B
Rationale: Infection from abrasions is the most likely cause of fever post-accident, as it's a common complication.
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The nurse must administer in one syringe a combined dose of two different insulins from two vials. Place the steps (Roman numerals) in the correct order.
- A. Cleanse tops of vials.
- B. Inject air into vial 1.
- C. Withdraw medication from vial 1.
- D. Change needles.
- E. Withdraw medication from vial 2.
- F. Inject air into vial 2.
Correct Answer: A,B,F,C,E
Rationale: The correct order is: Cleanse vials (I), inject air into vial 1 (II), inject air into vial 2 (VI), withdraw from vial 1 (III), withdraw from vial 2 (V). Changing needles (IV) is not standard.
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?
- A. Promazine (Sparine).
- B. Biperiden (Akineton).
- C. Thiothixene (Navane).
- D. Haloperidol (Haldol).
Correct Answer: B
Rationale: is an antiparkinsonian agent, used to counteract extrapyramidal side effects the client is experiencing
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 2 hours of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: NPH insulin peaks 4-12 hours after administration, so a snack around 3 PM helps prevent hypoglycemia during peak action.
The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?
- A. Alteration in cerebral tissue perfusion
- B. Fluid volume deficit
- C. Ineffective airway clearance
- D. Alteration in sensory perception
Correct Answer: B
Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.
In many cultures, pregnancy is viewed as a natural rather than a medical condition. How does this affect prenatal care?
- A. Pregnant women often seek prenatal care later and less frequently.
- B. These views have little effect on prenatal care.
- C. Pregnant women believe prenatal care is harmful to the fetus.
- D. These views often result in increased rates of fetal mortality.
Correct Answer: A
Rationale: Viewing pregnancy as natural (A) often leads to delayed or less frequent prenatal care, impacting monitoring. Harmful beliefs (C) or increased mortality (D) are not directly implied.