Nokea
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glascow coma scale.
Correct Answer: A
Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.
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The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.
Four 6-month-old children arrive at the clinic for diphtheria-pertussis-tetanus immunization. Which child can safely receive the immunization at this time?
- A. the child with a runny nose
- B. the child who experienced a seizure after the last immunization
- C. the child who experienced a life-threatening allergic reaction after the last immunization
- D. the child with a temperature of 102°F
Correct Answer: A
Rationale: A mild runny nose is not a contraindication for the DTaP vaccine, whereas seizures, severe allergic reactions, or fever indicate a need to delay immunization.
Two Mexican immigrant families live closely together and share goods, services, and childcare. To which of the following family structures does this model correspond?
- A. Kinship network
- B. Binuclear
- C. Nuclear
- D. Extended
Correct Answer: A
Rationale: A kinship network (A) involves close family units sharing resources, typical in some Mexican cultures. Extended (D) is broader, nuclear (C) is single-family, and binuclear (B) involves divorce.
A client is hospitalized in a long-term care facility because of Alzheimer disease. The client is incontinent of urine and feces. The nurse has delegated incontinent care to unlicensed assistive personnel (UAP). How frequently should the nurse advise that the UAP check the client for dryness?
- A. Every 2 hours
- B. Every hour
- C. When the client appears restless.
- D. Before meals and at bedtime
Correct Answer: A
Rationale: Checking every 2 hours (A) ensures timely care to prevent skin breakdown in an incontinent client. Hourly checks (B) are excessive, and checking only when restless (C) or before meals (D) is insufficient.
A client with diabetes visits the prenatal clinic at 28 weeks gestation. Which statement is true regarding insulin needs during pregnancy?
- A. Insulin requirements moderate as the pregnancy progresses.
- B. A decreased need for insulin occurs during the second trimester.
- C. Elevations in human chorionic gonadotrophin decrease the need for insulin.
- D. Fetal development depends on adequate insulin regulation.
Correct Answer: D
Rationale: Adequate insulin regulation is critical for fetal development in diabetic pregnancies.