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The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?
- A. He bends over to tie his shoes.
- B. He tells the nurse he takes a lot of pills every day.
- C. He ambulates daily.
- D. He tells the nurse he has ordered a medical identification bracelet.
Correct Answer: A
Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.
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The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the charge nurse.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.
The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
Joan is at lunch in the hospital cafeteria with a nurse coworker. Joan is very allergic to nuts and always carries her anaphylactic kit with her. Joan tells her coworker that there must have been nuts in something she ate because she is having increasing difficulty breathing. What should the nurse do immediately?
- A. Take her to the hospital emergency room
- B. Administer the medication in her friend's anaphylactic kit
- C. Call the floor for help
- D. Monitor the symptoms
Correct Answer: B
Rationale: Administering the anaphylactic kit medication (epinephrine) is the immediate action to reverse anaphylaxis, prioritizing airway patency.
The nurse is contributing to a staff education program about cancer screening. Which of the following findings should the nurse suggest including as a possible warning sign of cancer?
- A. recent diagnosis of benign prostatic hyperplasia
- B. unintentional weight loss of 15 lb (6.8 kg) over the past 3 months
- C. a doughy, mobile, golf ball-sized lesion under the skin on the thigh
- D. a fever, productive cough, and hoarseness for the past 5 days
Correct Answer: B
Rationale: Unintentional weight loss is a cancer warning sign. BPH is benign, a mobile lesion is likely benign, and cough/fever suggest infection.
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
- A. Alteration in comfort
- B. Alteration in mobility
- C. Alteration in skin integrity
- D. Alteration in O2 perfusion
Correct Answer: B
Rationale: Alteration in mobility is priority for a detached retina, as positioning and activity restrictions prevent further detachment. Comfort, skin integrity, and O2 perfusion are secondary concerns.