Nokea
The nurse is evaluating cerebral perfusion outcomes for a client with a subdural hematoma. The nurse evaluates which of the following as a favorable outcome for this client?
- A. Arterial blood gas POâ‚‚ of 98
- B. Increase in lethargy
- C. Pupils slow to react to light
- D. Temperature of 101°F
Correct Answer: A
Rationale: An arterial blood gas POâ‚‚ of 98 indicates adequate oxygenation, supporting cerebral perfusion, which is a favorable outcome for a subdural hematoma.
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A 3-year-old child had a PPD skin test 2 days ago. When the mother brings the child back to the clinic to have the nurse check the results, the nurse notes a 10 mm area of induration. This is considered
- A. an inconclusive skin test.
- B. a positive skin test.
- C. a negative skin test.
- D. too early to determine the results.
Correct Answer: B
Rationale: A 10 mm induration 48-72 hours post-PPD is positive in children, indicating TB exposure, especially in high-risk groups.
A client on the psychiatric unit is in an uncontrolled rage and is threatening other clients and staff. What is the most appropriate action for the nurse to take?
- A. Call security for assistance and prepare to sedate the client.
- B. Tell the client to calm down and ask him if he would like to play cards.
- C. Tell the client that if he continues his behavior he will be punished.
- D. Leave the client alone until he calms down.
Correct Answer: A
Rationale: Calling security and preparing for sedation ensures the safety of the client, other patients, and staff during an uncontrolled rage.
The nurse working in an outpatient pain clinic has the opportunity to teach a client with chronic back pain about nonpharmacological pain management. Which of the following would be most appropriate for the nurse to include when teaching? Select all that apply.
- A. music
- B. therapeutic massage
- C. stretching exercises
- D. relaxation
Correct Answer: A, B, C, D
Rationale: Music, therapeutic massage, stretching exercises, and relaxation are all evidence-based nonpharmacological methods to manage chronic pain.
The Joint Commission for Accreditation of Hospital Organizations (JCAHO) specifies that two client identifiers are to be used before administering medication. Which method is best for identifying patients using two patient identifiers?
- A. Take the medication administration record (MAR) to the room and compare it with the name and medical number recorded on the armband.
- B. Compare the medication administration record (MAR) with the client's room number and name on the armband.
- C. Request that a family member identify the client and then ask the client to state his name.
- D. Ask the client to state his full name and then to write his full name.
Correct Answer: A
Rationale: Comparing the MAR with the client's armband name and medical number ensures accurate identification using two reliable identifiers.
When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a:
- A. Plastic zip-lock bag
- B. Rubber tote
- C. Paper bag
- D. Padded manila envelope
Correct Answer: C
Rationale: A paper bag allows air circulation, preventing moisture that could degrade biological evidence.