Nokea
The nurse is caring for a client who just had a supratentorial craniotomy to remove a tumor. The nurse will implement which of the following in the client's plan of care? Select all that apply.
- A. check the dressing every 8 hours for excessive drainage
- B. assess the pupils for signs of increased intracranial pressure
- C. position the client flat with the head rotated away from the surgical site
- D. monitor the client's respiratory status, including rate and pattern of breathing
- E. notify the health care provider if the dressing is saturated or the client has more than 50 mL of drainage in 8 hours
Correct Answer: B, D, E
Rationale: Monitoring pupils, respiratory status, and excessive drainage are critical to detect complications like increased intracranial pressure. Positioning flat is incorrect; the head should be elevated.
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The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.
- A. normal childhood
- B. family history of depression
- C. recent major life change
- D. Lipitor used to treat high blood pressure
Correct Answer: B, C
Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.
A 54-year-old female is brought into the ED by her spouse. The client's spouse tells the nurse the client has been experiencing muscle stiffness, increased perspiration, and anxiety. The nurse obtains bloodwork as ordered by the physician, including a complete blood count and a comprehensive metabolic panel. For which result should the nurse immediately notify the physician?
- A. calcium 7.2 mg/dL
- B. alkaline phosphatase 120 IU/L
- C. sodium 143 mEq/L
- D. creatinine 0.8 mg/dL
Correct Answer: A
Rationale: Hypocalcemia (calcium 7.2 mg/dL, normal 8.5–10.2) can cause muscle stiffness and anxiety, requiring immediate notification. Other results are normal.
The physician has made a diagnosis of 'shaken child' syndrome for a 13-month-old who was brought to the emergency room after a reported fall from his highchair. Which finding supports the diagnosis of 'shaken child' syndrome?
- A. Fracture of the clavicle
- B. Periorbital bruising
- C. Retinal hemorrhages
- D. Fracture of the humerus
Correct Answer: C
Rationale: Retinal hemorrhages are a hallmark of shaken baby syndrome due to the shearing forces from violent shaking causing bleeding in the retina.
The nurse is evaluating the intake and output of a client for the first 12 hours following an abdominal cholecystectomy. Which finding should be reported to the physician?
- A. Output of 10 mL from the Jackson-Pratt drain
- B. Foley catheter output of 285 mL
- C. Nasogastric tube output of 150 mL
- D. Absence of stool
Correct Answer: D
Rationale: Absence of stool post-cholecystectomy may indicate a complication like ileus or obstruction, requiring physician evaluation.
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.