Nokea
The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?
- A. Widening pulse pressure
- B. Tachycardia
- C. Hyperthermia
- D. Hypotension
Correct Answer: A
Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.
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Which of the following indicates that a 5-month-old weighing 15 lb and being treated for dehydration has a normal urine output? The urine output is:
- A. 1 to 2 mL/kg/hour.
- B. 3 to 5 mL/kg/hour.
- C. 6 to 8 mL/kg/hour.
- D. 10 to 12 mL/kg/hour.
Correct Answer: A
Rationale: Normal urine output for an infant is 1 to 2 mL/kg/hour, indicating adequate hydration. Higher outputs may suggest overhydration or other issues.
The nurse is planning care for a client who chews the fingers constantly. Before applying mitten restraints, the nurse could try which of the following interventions? Select all that apply.
- A. Ask the client to rub lotion over the hands every day after bathing.
- B. Encourage physical activity, such as ambulation.
- C. Provide frequent contacts for communication and socialization.
- D. Provide family education.
- E. Encourage involvement of family and friends.
Correct Answer: A,B,C,E
Rationale: Non-restrictive interventions like applying lotion, encouraging physical activity, providing social interaction, and involving family can address the behavior's underlying causes, such as anxiety or sensory needs, while promoting client autonomy and engagement.
A client is trying to lose weight at a moderate pace. The client eliminates 1,000 calories per day from his normal intake, how many pounds would he lose in 1 week?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: A
Rationale: A 1,000-calorie daily deficit equals 7,000 calories per week. Since 3,500 calories approximate one pound of fat, the client would lose about 2 pounds per week.
On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she remarks to the nurse, 'I am so scared of this cancer. I should have quit smoking years ago. Now I've brought all this fear and sadness on myself and now my family.' The nurse should tell the client:
- A. It's normal to be scared. I would be, too. We'll help you through it.'
- B. Do you feel guilty because you smoked?'
- C. Don't be so hard on yourself. You don't know if your smoking caused the cancer.'
- D. I can imagine how scared you are. What is it about cancer that you're afraid of?'
Correct Answer: D
Rationale: Acknowledging the client's fear and exploring specific concerns fosters therapeutic communication, helping address her emotions effectively.
The nurse is teaching a client with a new diagnosis of type 1 diabetes about sick day management. Which of the following instructions should be included? Select all that apply.
- A. Continue taking insulin.
- B. Monitor blood glucose frequently.
- C. Avoid eating solid foods.
- D. Drink plenty of fluids.
- E. Contact the healthcare provider if vomiting persists.
Correct Answer: A, B, D, E
Rationale: Continuing insulin, frequent glucose monitoring, fluid intake, and contacting the provider prevent complications during illness.