Nokea
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting cerebral blood vessels. Which physician order would serve this purpose?
- A. Hyperventilation per mechanical ventilation
- B. Insertion of a ventricular shunt
- C. Furosemide (Lasix)
- D. Solu medrol
Correct Answer: A
Rationale: Hyperventilation reduces PaCO2, causing cerebral vasoconstriction, which decreases cerebral blood flow and edema. The other options address pressure or fluid but not vasoconstriction.
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A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- A. Reverse the direction of the blood flow
- B. Allow better blood supply to the lungs
- C. Relieve pressure on the ventricles
- D. Prevent the need for further correction
Correct Answer: B
Rationale: The modified Blalock-Taussig procedure creates a shunt to improve pulmonary blood flow in Tetralogy of Fallot, enhancing lung oxygenation.
The nurse is developing a care plan for a client with hepatitis A. The nurse knows that the primary routes of transmission of this hepatitis virus are which of the following? Select all that apply.
- A. sputum
- B. blood
- C. feces
- D. contaminated food
Correct Answer: C,D
Rationale: Hepatitis A is transmitted primarily via the fecal-oral route, through contaminated food or water (D) and feces (C).
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated hepatic enzymes
Correct Answer: D
Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets, so elevated hepatic enzymes are a key finding.
The nurse is caring for a 28-year-old female with a long history of heroin addiction. The client tells the nurse that she started off using a small amount recreationally, but as time went on, she needed more and more heroin to feel a high. The nurse recognizes this as
- A. addiction.
- B. dependence.
- C. tolerance.
- D. withdrawal.
Correct Answer: C
Rationale: Tolerance is the need for increasing doses to achieve the same effect, as described in the client’s heroin use.