Nokea
The nurse has just received the change of shift report. Which client should the nurse assess first?
- A. A client with a supratentorial tumor awaiting surgery
- B. A client admitted with a suspected subdural hematoma
- C. A client recently diagnosed with akinetic seizures
- D. A client transferring to the neuro rehabilitation unit
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment to prevent deterioration.
You may also like to solve these questions
A client is complaining of chest pain. Nursing assessment reveals a BP of 78/40, shortness of breath, and third-degree AV block on the heart monitor. What medication would the nurse prepare for initial administration?
- A. Atropine
- B. Verapamil (Calan)
- C. Lidocaine (Xylocaine)
- D. Procainamide (Pronestyl)
Correct Answer: A
Rationale: Third-degree AV block with hypotension (BP 78/40) requires atropine to increase heart rate by blocking vagal activity, improving cardiac output.
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
Which of the following groups of neonates should be screened for hearing loss?
- A. Premature neonates.
- B. Neonates with risk factors for hearing loss.
- C. Neonates with abnormal Apgar scores.
- D. All neonates.
Correct Answer: D
Rationale: Universal newborn hearing screening is recommended for all neonates (D) to detect hearing loss early. Premature neonates (A), those with risk factors (B), or abnormal Apgar scores (C) are included but not exclusive.
The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin:
- A. Slows contractions of the heart
- B. Dilates coronary blood vessels
- C. Increases the ventricular fill time
- D. Strengthens contractions of the heart
Correct Answer: B
Rationale: Nitroglycerin dilates coronary blood vessels, improving blood flow to the myocardium and relieving angina.
Which type of behavior modification is most likely to benefit a client who has a severe phobia regarding spiders?
- A. Positive reinforcement
- B. Negative reinforcement
- C. Desensitization
- D. Aversion therapy
Correct Answer: C
Rationale: Desensitization (C), gradually exposing the client to spiders, is most effective for phobias. Other methods (A, B, D) are less specific.