Nokea
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
- A. Keep the head of the bed elevated 30–45 degrees.
- B. Administer acetaminophen for headache.
- C. Provide frequent oral care.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (B), oral care (C), and breathing exercises (D) are supportive but less critical for ICP control.
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A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split-thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24-48 hours postburn?
- A. Pain related to tissue damage from burns
- B. Potential for infection related to contamination of wounds
- C. Fluid volume deficit related to increased capillary permeability
- D. Potential for impaired gas exchange related to edema of respiratory tract
Correct Answer: D
Rationale: (A, B, C) These answers are all correct; however, maintenance of airway is the top priority. Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The nurse should:
- A. Apply ice to the fracture site
- B. Encourage active range of motion
- C. Keep the arm in a dependent position
- D. Massage the arm daily
Correct Answer: A
Rationale: Ice reduces swelling and pain at the fracture site. Active motion is limited, dependent positioning increases swelling, and massage is not recommended.
The nurse is removing a peripherally inserted central catheter (PICC). The nurse should position the patient in which position?
- A. Fowlers
- B. Right side lying
- C. Left side lying
- D. Trendelenburg
Correct Answer: D
Rationale: Trendelenburg position (head down) is used when removing a PICC line to reduce the risk of air embolism by increasing venous pressure. Fowler’s, right, or left side-lying positions do not provide this protection.
The client is admitted with a diagnosis of abruptio placenta. Which diagnostic test is most likely to be ordered?
- A. Ultrasound
- B. Fetal heart monitoring
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Ultrasound can confirm placental separation in abruptio placenta and fetal heart monitoring assesses for distress due to hypoxia. Both tests are critical for diagnosis and management.
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU. A low-phenylalanine diet, healthy snacks, and preventing mental retardation are correct understandings.