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The nurse notes that the fall might also cause a possible head injury. The patient will be observed for signs of increased intracranial pressure which include:
- A. Narrowing of the pulse pressure
- B. Vomiting
- C. Periorbital edema
- D. A positive Kernig's sign
Correct Answer: C
Rationale: Periorbital edema is a sign of increased intracranial pressure. It is caused by fluid accumulation around the eyes due to compromised drainage. Narrowing of the pulse pressure is more indicative of shock than increased intracranial pressure. While vomiting can be a sign of increased intracranial pressure, it is not as specific as periorbital edema. A positive Kernig's sign is associated with meningitis, not increased intracranial pressure.
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All of the following are seen in a child with measles. Which one is not?
- A. Reddened eyes
- B. Coryza
- C. Pustule
- D. Cough
Correct Answer: C
Rationale: Measles typically presents with symptoms like reddened eyes, coryza (inflammation of the mucous membrane in the nose), and cough. However, pustules are not a common symptom of measles. Pustules are more characteristic of conditions like chickenpox rather than measles. Understanding these distinctions is crucial for accurate diagnosis and appropriate treatment.
Which of the four phases of emergency management is defined as 'sustained action that reduces or eliminates long-term risk to people and property from natural hazards and their effects'?
- A. Recovery
- B. Mitigation
- C. Response
- D. Preparedness
Correct Answer: B
Rationale: The correct answer is B, 'Mitigation.' Mitigation is the phase of emergency management that focuses on sustained actions aimed at reducing or eliminating long-term risks to people and property from natural hazards. Recovery (A) involves restoring and rebuilding infrastructure, housing, and services after a disaster. Response (C) deals with immediate actions taken to save lives and prevent further damage during a disaster. Preparedness (D) involves planning, training, and equipping organizations and communities to effectively respond to emergencies.
In monitoring the patient in PACU, the nurse correctly identifies that checking the patient's vital signs is done every:
- A. 1 hour
- B. 5 minutes
- C. 15 minutes
- D. 30 minutes
Correct Answer: A
Rationale: Correct Answer: A - Vital signs monitoring in the PACU (Post-Anesthesia Care Unit) is typically done every hour to closely monitor the patient's condition during the immediate postoperative period. This frequency allows the nurse to promptly identify any changes in the patient's vital signs and intervene as necessary. Choice B (5 minutes) is too frequent for routine vital signs monitoring in the PACU and may not allow for a comprehensive assessment of the patient's stability. Choice C (15 minutes) and Choice D (30 minutes) are also not in line with the standard practice of vital signs monitoring in the PACU, which is typically hourly.
This study, which is an in-depth study of one boy, is a:
- A. case study
- B. longitudinal study
- C. cross-sectional study
- D. evaluative study
Correct Answer: A
Rationale: The correct answer is 'A: case study.' A case study involves an in-depth examination of a single individual, group, or event. In this scenario, focusing on one boy aligns with the definition of a case study. The other options are not applicable: B) A longitudinal study involves following subjects over a period of time, C) A cross-sectional study examines a population at a single point in time, and D) An evaluative study assesses the effectiveness of a program or intervention, which is not the focus of the given scenario.
The nurse cares for a hospitalized adolescent with the diagnosis of anorexia nervosa. Which nursing goal is a priority for this client?
- A. Encourage effective coping skills
- B. Restore normal eating habits
- C. Stop weight loss or restore weight
- D. Promote realistic self-image
Correct Answer: C
Rationale: In the treatment of anorexia nervosa, stopping weight loss or restoring weight is a critical priority. This helps address the immediate health risks associated with severe malnutrition and supports the client's physical well-being. Encouraging effective coping skills, restoring normal eating habits, and promoting a realistic self-image are essential aspects of treatment but may come later in the care plan once the immediate risk of severe weight loss has been addressed.