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 Glasgow coma scale.
Correct Answer: A
Rationale: Normal ICP is 5-15 mmHg. A reading of 17 mmHg is elevated, indicating potential brain swelling, and requires immediate notification of the physician. The Glasgow scale complements but does not replace ICP monitoring.
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The client is prescribed levothyroxine (Synthroid) for hypothyroidism. Which instruction should the nurse include?
- A. Take the medication at bedtime.'
- B. Report palpitations or chest pain.'
- C. Increase dietary fiber to prevent constipation.'
- D. Take the medication with meals.'
Correct Answer: B
Rationale: Levothyroxine can cause cardiac side effects like palpitations or chest pain, which should be reported. It is taken in the morning, fiber is not directly related, and food reduces absorption.
A client with a history of a stroke is being discharged. The nurse should teach the client to:
- A. Avoid all physical activity
- B. Use assistive devices as needed
- C. Limit social interactions
- D. Eat a high-sodium diet
Correct Answer: B
Rationale: Assistive devices (e.g., cane, walker) promote safety and mobility post-stroke. Physical activity is encouraged, social interactions are beneficial, and sodium should be limited.
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerostomia
- B. Candidiasis
- C. Leukoplakia
- D. Stomatitis
Correct Answer: C
Rationale: Leukoplakia cannot be rubbed off.
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
- A. State, 'You have an angel in heaven.'
- B. Discourage the parents from seeing the baby.
- C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.
- D. Reassure the parents that they can have other children.
Correct Answer: C
Rationale: This is not a supportive statement. There are also no data to indicate the family's religious beliefs. Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say 'good-bye.' Parents need time to get to know their baby. This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
The nurse is caring for a client with a history of a pneumothorax who has a chest tube in place. The nurse should:
- A. Clamp the chest tube during transport
- B. Strip the chest tube every hour
- C. Keep the drainage system below chest level
- D. Empty the drainage system daily
Correct Answer: C
Rationale: Keeping the drainage system below chest level prevents fluid backflow into the chest. Clamping risks pneumothorax, stripping is outdated, and emptying is per protocol, not daily.