Nokea
The nurse is caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s
- A. anterior fontanel
- B. bilateral hearing
- C. pulse pressure
- D. Babinski reflex
Correct Answer: A
Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.
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A client is being evaluated for carpal tunnel syndrome. The nurse is observed asking the client to place the backs of her hands together and flex them at the same time. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's
- D. Brudzinski's
Correct Answer: A
Rationale: Phalen's maneuver involves flexing the wrists with the backs of the hands together to assess for carpal tunnel syndrome, as it may reproduce symptoms. Tinel's sign involves tapping over the median nerve. Kernig's and Brudzinski's are tests for meningitis, not carpal tunnel syndrome.
The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?
- A. Expiratory wheezes
- B. Blurred vision
- C. Ascites
- D. Dilated pupils
Correct Answer: C
Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.
The nurse is caring for a client with a history of headaches who has come to the clinic reporting a 'bad migraine.' The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?
- A. Blood pressure of 136/88 mm Hg
- B. Flat affect and drowsiness
- C. Nausea and poor appetite
- D. Respiratory rate of 12/min
Correct Answer: B
Rationale: Flat affect and drowsiness in a migraine are atypical and may indicate a more serious condition like a neurological event, requiring urgent evaluation. Nausea and poor appetite are common in migraines, and the BP and respiratory rate are within normal limits.
When the nurse is caring for a client receiving a neuroleptic medication exhibiting torticollis and involuntary muscle movement, what is the priority nursing action?
- A. Have respiratory support equipment available
- B. Administer an antiemetic medication
- C. Monitor the client’s temperature closely
- D. Administer an antihistamine
Correct Answer: A
Rationale: Have respiratory support equipment available. These side effects could lead to respiratory failure, necessitating immediate respiratory support.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).