Nokea
The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?
- A. Displacement of brain tissue
- B. Increase in cerebral perfusion
- C. Increase in the serum pH level
- D. Leakage of cerebrospinal fluid
Correct Answer: A
Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased perfusion. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.
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The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
Which intervention is most appropriate for a client with Bell's palsy experiencing eye dryness?
- A. Apply warm compresses to the affected eye.
- B. Administer oral antihistamines.
- C. Use artificial tears as prescribed.
- D. Cover the unaffected eye with a patch.
Correct Answer: C
Rationale: Artificial tears prevent corneal damage from eye dryness in Bell's palsy due to incomplete eye closure.
When the nurse observes that the client has difficulty swallowing the capsule of medication, which action is best to take?
- A. Soak the capsule in water until soft.
- B. Tell the client to chew the capsule.
- C. Moisten the capsule in the client's mouth.
- D. Offer water before giving the capsule.
Correct Answer: D
Rationale: Offering water before giving the capsule aids swallowing without altering the medication's integrity.
The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.
Which teaching topics should the nurse cover before discharge? Select all that apply.
- A. Dietary restrictions
- B. Avoiding heavy lifting
- C. Staying out of bright sunlight
- D. Missed doses
- E. Bruising or blood in urine
- F. Need for frequent laboratory work
Correct Answer: A,D,E,F
Rationale: Warfarin requires dietary consistency, instructions on missed doses, monitoring for bleeding (bruising/blood in urine), and frequent INR checks.