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.
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The goal of nursing is to put the patient in the best condition for nature to act upon him'. This was stated by
- A. Henderson
- B. Jean Watson
- C. Marta Rogers
- D. Florence Nightingale
Correct Answer: D
Rationale: This quote reflects a historical view of nursing as facilitating natural healing, attributed to Florence Nightingale, the founder of modern nursing. In her 1859 work, *Notes on Nursing*, she emphasized optimizing the patient's environment cleanliness, air, and rest for recovery. Henderson defined nursing through 14 basic needs, Watson focused on caring theory, and Rogers developed a science of unitary beings none match this phrasing. Nightingale's philosophy shaped nursing's focus on holistic care, influencing practice for centuries by prioritizing patient conditions over direct intervention.
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Monitoring I&O ensures fluid balance with hyperosmotic enteral feeding.
Which of the following nursing intervention is appropriate to prevent pulmonary embolus in a patient who is prescribed bed rest?
- A. Limit the client's fluid intake
- B. Encourage deep breathing and coughing
- C. Use the knee gatch when the client is in bed
- D. Teach the patient to move legs in bed
Correct Answer: D
Rationale: Bed rest risks venous stasis, a pulmonary embolus cause. Leg movement promotes circulation, preventing clots from forming and traveling to lungs. Fluid limits dehydration but not emboli directly, deep breathing aids lungs but not veins, and knee gatch increases stasis. Nurses teach exercises, reducing thromboembolism risk, enhancing recovery safety.
Which assessment finding indicates a potential musculoskeletal complication of immobility?
- A. Increased muscle tone
- B. Active range of motion (ROM)
- C. Contractures
- D. Strong and flexible joints
Correct Answer: C
Rationale: Contractures permanent muscle and tendon shortening indicate a musculoskeletal complication of immobility, restricting joint movement due to prolonged stillness. High muscle tone might suggest other conditions, while active motion and strong joints reflect health, not issues. Nurses assess for this to initiate stretching or therapy, countering the stiffening that immobility causes, ensuring musculoskeletal function is preserved as much as possible in affected patients.
The nurse returned to check Mr. Gary as promised. This is an example of?
- A. Fidelity
- B. Veracity
- C. Justice
- D. Beneficence
Correct Answer: A
Rationale: Returning as promised is fidelity (A) keeping commitments, per ethics. Veracity (B) is truth, justice (C) fairness, beneficence (D) good not promise-specific. A reflects the nurse's reliability, fostering trust with Mr. Gary, aligning with fidelity's ethical role in nursing, making it correct.