Nokea
The nurse is performing a neurological assessment on a client post right cerebrovascular accident. Which finding, if observed by the nurse, would warrant immediate attention?
- A. Decrease in level of consciousness
- B. Loss of bladder control
- C. Altered sensation to stimuli
- D. Emotional lability
Correct Answer: A
Rationale: A decrease in the level of consciousness is a critical finding that would warrant immediate attention in a client post right cerebrovascular accident. This change may indicate an increase in intracranial pressure, leading to inadequate oxygenation of the brain. It could also reveal the presence of a transient ischemic attack, which may signal an impending thrombotic cerebrovascular accident. Loss of bladder control (choice B) can be managed and monitored but does not indicate an immediate threat to the client's life. Altered sensation to stimuli (choice C) can be a concerning finding but may not require immediate attention unless it affects the client's safety. Emotional lability (choice D) may be distressing for the client but does not pose an immediate risk to their health compared to a decrease in the level of consciousness.
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While suctioning the endotracheal tube of an adult client, what level of pressure should the nurse apply?
- A. 70-80 mmHg
- B. 100-120 mmHg
- C. 150-170 mmHg
- D. 200 mmHg
Correct Answer: B
Rationale: When suctioning the endotracheal tube of an adult client, the nurse should set the suction apparatus at a level no higher than 150 mmHg, with a preferable level between 100 and 120 mmHg. Suction pressure that is too high can contribute to the client's hypoxia. Alternatively, too low suction pressure may not clear adequate amounts of secretions. Choice A (70-80 mmHg) is too low and may not effectively clear secretions. Choices C (150-170 mmHg) and D (200 mmHg) are too high and can potentially harm the client by causing hypoxia or damaging the airway.
The parents of a child with a hernia are instructed by the nurse on measures to reduce the hernia. Which statement indicates the parents understand the care for their child?
- A. We will encourage our child to cough every few hours on a daily basis.
- B. We will make sure that our child participates in physical activity every day.
- C. We will provide comfort measures to reduce any crying periods by our child.
- D. We will be sure to give our child a Fleet enema every day to prevent constipation.
Correct Answer: C
Rationale: The correct answer is providing comfort measures to reduce any crying periods by the child. This can include offering a warm bath, avoiding upright positioning, and using other comfort measures to reduce crying, which can help reduce a hernia. Encouraging coughing or physical activity can increase strain on the hernia. Giving a Fleet enema daily for constipation is not recommended as it can also increase strain on the hernia.
You have accompanied the physician into the family waiting room to tell a young husband that his wife has not survived the car accident she was in. The husband is crying and distraught. What is the most appropriate approach to supporting this family member?
- A. Ask if he would like to donate his wife's organs
- B. Sit quietly with him
- C. Ask about funeral arrangements
- D. Consult social services
Correct Answer: B
Rationale: The most caring and supportive approach in a time of extreme distress is usually to sit quietly with the distressed individual until they have had the opportunity to absorb the news and gather themselves. Providing a supportive presence is often the most valuable tool a caregiver can use when circumstances bring overwhelming emotional pain to those they are caring for. Asking about organ donation at this moment may come off as insensitive and should not be a priority. Inquiring about funeral arrangements and consulting social services can be addressed later, once the husband has had time to process the initial shock and emotions.
When assessing a patient suspected to have Hepatitis, a nurse notes the patient's eyes are yellow-tinged. Which of the following diagnostic results would further assist in confirming this diagnosis?
- A. Decreased serum Bilirubin
- B. Elevated serum ALT levels
- C. Low RBC and Hemoglobin with increased WBCs
- D. Increased Blood Urea Nitrogen level
Correct Answer: B
Rationale: Elevated serum ALT levels would further confirm the diagnosis of Hepatitis. ALT is a liver enzyme, and hepatitis is a liver disease. Elevated liver enzymes, such as ALT, often indicate liver damage. Choice A, 'Decreased serum Bilirubin,' is incorrect as elevated bilirubin levels are typically seen in hepatitis due to impaired bilirubin metabolism. Choices C and D are unrelated to confirming a diagnosis of hepatitis as they describe findings not specific to liver function or hepatitis. Low RBC and Hemoglobin with increased WBCs (Choice C) suggest a different condition like anemia or infection, not specific to liver disease. Increased Blood Urea Nitrogen level (Choice D) is more indicative of kidney function rather than liver function, thus not helpful in confirming hepatitis.
A child is suspected of suffering from intussusception. The nurse should be alert to which clinical manifestation of this condition?
- A. Tender, distended abdomen
- B. Presence of fecal incontinence
- C. Incomplete development of the anus
- D. Infrequent and difficult passage of dry stools
Correct Answer: A
Rationale: Intussusception is an invagination of a section of the intestine into the distal bowel, and it is the most common cause of bowel obstruction in children aged 3 months to 6 years. A tender, distended abdomen is a typical clinical manifestation of intussusception. The presence of fecal incontinence is not a characteristic presentation of intussusception; it describes encopresis, which generally affects preschool and school-aged children but is not specific to intussusception. Incomplete development of the anus describes imperforate anus, a disorder diagnosed in the neonatal period, not intussusception. The infrequent and difficult passage of dry stools is characteristic of constipation, a common issue in children that can occur at any age, although it often peaks at 2 to 3 years old.