Nokea
The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?
- A. Suction the client every hour
- B. Maintain the head of the bed at 30 degrees
- C. Encourage the client to cough frequently
- D. Administer a bolus of intravenous fluids
Correct Answer: B
Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.
You may also like to solve these questions
Which of the following is NOT a contraindication in taking ORAL temperature?
- A. Quadriplegic
- B. Presence of NGT
- C. Dyspnea
- D. Nausea and Vomitting
Correct Answer: A
Rationale: Quadriplegia isn't an oral temp contraindication e.g., a paralyzed patient can hold a thermometer if alert. NGT (obstruction), dyspnea (breathing), and nausea (gagging) preclude it. Nurses opt for alternatives e.g., axillary per safety protocols.
Which of the following statement is NOT true about crisis intervention?
- A. Aims to restore pre-crisis state
- B. Short term
- C. Requires long term therapy
- D. Focuses on immediate needs
Correct Answer: C
Rationale: Crisis intervention restores pre-crisis (A), is short-term (B), immediate-focused (D) 'requires long-term therapy' (C) isn't true, as it's brief, per Caplan. C's duration contradicts, making it untrue.
Small for gestational age and large for gestational age infants have polycythemia because of:
- A. Hypocalcemia
- B. Hypoglycemia
- C. Hypoxia
- D. Hypothermia
Correct Answer: C
Rationale: Polycythemia (high red blood cell count) in SGA and LGA infants relates to intrauterine conditions. Hypocalcemia (choice A) affects calcium, not blood cells. Hypoglycemia (choice B) is metabolic, common in both, but unrelated to polycythemia. Hypoxia (choice C) triggers erythropoietin release, increasing RBCs; SGA infants face placental insufficiency, LGA infants (e.g., diabetic mothers) experience transient hypoxia. Hypothermia (choice D) doesn't cause polycythemia. C is correct, as hypoxia drives this adaptation. Nurses monitor hematocrit, manage viscosity risks (e.g., dehydration), and support oxygenation, preventing complications.
Which of the following statement best describe spiritual care in nursing?
- A. Ignoring beliefs
- B. Supporting spiritual needs
- C. A medical fix
- D. A one-time talk
Correct Answer: B
Rationale: Spiritual care is supporting spiritual needs (B), per nursing e.g., prayer support. Not ignoring (A), not medical (C), not one-time (D) holistic focus. B best defines its role, enhancing Mr. Gary's well-being, making it correct.
The most important nursing intervention to correct skin dryness is:
- A. Avoid bathing the patient until the condition is remedied, and notify the physician
- B. Ask the physician to refer the patient to a dermatologist, and suggest that the patient wear home-laundered sleepwear
- C. Consult the dietitian about increasing the patient's fat intake, and take necessary measures to prevent infection
- D. Encourage the patient to increase his fluid intake, use non-irritating soap when bathing the patient, and apply lotion to the involved areas
Correct Answer: D
Rationale: Hydration, gentle soap, and lotion address dryness and prevent cracking.