Nokea
The nurse is caring for a client with a closed head injury. Which finding suggests increasing intracranial pressure?
- A. Pulse rate of 100
- B. Widening pulse pressure
- C. Respiratory rate of 20
- D. Temperature of 99°F
Correct Answer: B
Rationale: Widening pulse pressure (e.g., 140/60) indicates rising intracranial pressure post-head injury, reflecting Cushing's triad with bradycardia and respiratory changes pulse, respiration, or mild fever alone don't confirm this. Nurses report this, signaling brain herniation risk, necessitating urgent intervention like mannitol or surgery.
You may also like to solve these questions
A nurse is caring for a client receiving oxygen therapy via a mask. What is an important nursing intervention to prevent pressure ulcers on the client's face?
- A. Frequently adjusting the mask to relieve pressure
- B. Applying petroleum jelly to the areas of skin contact
- C. Placing padding between the mask and the client's skin
- D. Assessing the client's facial skin integrity regularly
Correct Answer: C
Rationale: Placing padding between the mask and skin (C) prevents pressure ulcers by cushioning contact points, reducing friction and pressure. Frequent adjustments (A) disrupt fit. Petroleum jelly (B) compromises seal. Regular assessment (D) detects, not prevents. Padding is proactive, per skin care standards, ensuring mask safety.
The nurse is caring for a client following a TURP. The client's catheter becomes obstructed. The nurse should:
- A. Notify the physician immediately
- B. Increase the flow rate of the irrigating solution
- C. Milk the catheter to remove the obstruction
- D. Remove the catheter and replace it with a new one
Correct Answer: A
Rationale: Notifying the physician immediately for an obstructed catheter post-TURP prevents bladder distention or bleeding increasing flow risks pressure, milking may dislodge clots unsafely, and removal isn't nurse-initiated. Nurses act fast, ensuring patency, critical in urologic surgery.
The nurse is teaching the client with insulin-dependent diabetes the signs of hypoglycemia. Which of the following signs is associated with hypoglycemia?
- A. Tremulousness
- B. Slow pulse
- C. Nausea
- D. Flushed skin
Correct Answer: A
Rationale: Tremulousness is a classic sign of hypoglycemia in insulin-dependent diabetes, resulting from the autonomic nervous system's response to low glucose, triggering adrenaline release shakiness signals urgent need for sugar. Slow pulse, nausea, or flushed skin align more with other conditions or hyperglycemia. Nurses teach this symptom for self-recognition, enabling rapid intervention with glucose sources, preventing severe outcomes like seizures, critical for diabetes management.
The nurse is planning care for a client with a chronic illness. Which intervention reflects tertiary prevention?
- A. Screening the client for depression
- B. Teaching the client strategies for living with the illness
- C. Encouraging the client to receive an annual flu vaccine
- D. Educating the client about preventing transmission of illness
Correct Answer: B
Rationale: Tertiary prevention optimizes life with a chronic illness, reducing its impact post-diagnosis. Teaching strategies for living with it like pacing activities for arthritis helps the client adapt, minimizing disability and enhancing function, a nursing priority. Screening for depression is secondary, detecting new issues, not managing the existing one. An annual flu vaccine is primary, preventing unrelated illness, not addressing the chronic condition's effects. Educating about transmission fits infectious cases, not all chronic ones. This intervention tailored coping reflects nursing's role in rehabilitation, ensuring clients thrive despite limits. For instance, teaching a heart failure client fluid management cuts readmissions, aligning with tertiary care's focus on sustaining quality of life through practical, illness-specific support.
Prescriptive theories:
- A. Have the ability to explain, relate and in some situations predict nursing phenomena
- B. Describe phenomena
- C. Provide a structural framework for broad abstract ideas
- D. Reflect practice and address specific phenomena
Correct Answer: D
Rationale: Prescriptive theories in nursing specify actions for specific situations, reflecting practice and addressing phenomena like pain management with concrete interventions (e.g., administer analgesics). Unlike descriptive theories, which only describe (e.g., pain's nature), or explanatory ones, which explain and predict (e.g., why pain occurs), prescriptive theories guide what nurses should do, offering practical direction. Explaining, relating, and predicting fit mid-range or grand theories, not prescriptive ones' narrow focus. Providing a broad framework suits grand theories (e.g., Orem's), not prescriptive specificity. Reflecting practice and addressing phenomena captures prescriptive theories' role bridging theory to actionable care, like protocols for patient symptoms, making this the most precise definition in nursing theory application.