Nokea
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider about which of the following changes in the client's condition?
- A. Widening pulse pressure.
- B. Decrease in the pulse rate.
- C. Dilated, fixed pupils.
- D. Decrease in level of consciousness (LOC).
Correct Answer: A,B,C,D
Rationale: All listed changes are critical signs of increasing ICP. Widening pulse pressure (Cushing's triad), bradycardia, dilated fixed pupils, and decreased LOC indicate neurological deterioration requiring immediate notification of the health care provider for intervention.
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A client has sudden, severe pain in his back and chest, accompanied by shortness of breath. The client describes the pain as a 'tearing' sensation. The physician suspects the client is experiencing a dissecting aortic aneurysm. The code cart is brought into the room because one complication of a dissecting aneurysm is:
- A. Cardiac tamponade
- B. Stroke
- C. Pulmonary edema
- D. Myocardial infarction
Correct Answer: A
Rationale: A dissecting aortic aneurysm can rupture into the pericardial space, causing cardiac tamponade, a life-threatening complication requiring emergency intervention (hence the code cart). Stroke, pulmonary edema, and myocardial infarction are less common or indirect complications.
A client with a suspected small bowel obstruction reports severe pain and vomiting. Which diagnostic test should the nurse prepare the client for first?
- A. Abdominal X-ray.
- B. Barium enema.
- C. Colonoscopy.
- D. CT scan.
Correct Answer: A
Rationale: An abdominal X-ray is typically the first diagnostic test for a suspected small bowel obstruction to identify air-fluid levels or free air. Barium enema and colonoscopy are contraindicated in acute obstruction, and a CT scan may follow for detailed imaging. CN: Reduction of risk potential; CL: Synthesize
The client with Addison's disease is taking glucocorticoids. Which of the following statements indicates that the client understands how to take the medication?
- A. Various circumstances increase the need for glucocorticoids, so I will need to adjust the dosage.'
- B. My need for glucocorticoids will stabilize and I will be able to take a predetermined dose once a day.'
- C. Glucocorticoids are cumulative, so I will take a dose every third day.'
- D. I must take a dose every 6 hours to ensure consistent blood levels of glucocorticoids.'
Correct Answer: A
Rationale: Glucocorticoid needs vary with stress, requiring dose adjustments in Addison's disease to prevent adrenal crisis.
The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
Which of the following is contraindicated for a client with seizure precautions?
- A. Encouraging him to perform his own personal hygiene.
- B. Allowing him to wear his own clothing.
- C. Assessing oral temperature with a glass thermometer.
- D. Encouraging him to be out of bed.
Correct Answer: C
Rationale: Using a glass thermometer is contraindicated due to the risk of breakage and injury during a seizure. Personal hygiene, wearing own clothing, and being out of bed are safe and promote independence.