Nokea
The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?
- A. Altered level of consciousness is a late sign of increased ICP.'
- B. Elevated temperature is the earliest indication of increased ICP.'
- C. Late signs of increased ICP include narrowed pulse pressure and a lowered heart rate.'
- D. Late signs of increased ICP include increased systolic blood pressure and a widened pulse pressure.'
Correct Answer: D
Rationale: Late ICP signs include Cushing’s triad: increased systolic BP, widened pulse pressure, and bradycardia, reflecting brainstem compression.
You may also like to solve these questions
A client with clotting disorder has an order to continue Lovenox (enoxaparin) injections after discharge. The nurse should teach the client that Lovenox injections should:
- A. Be injected into the deltoid muscle
- B. Be injected into the abdomen
- C. Aspirate after the injection
- D. Clear the air from the syringe before injections
Correct Answer: B
Rationale: Lovenox is injected into the abdomen to ensure proper subcutaneous absorption and minimize bruising.
The client using a diaphragm should be instructed to:
- A. Refrain from keeping the diaphragm in longer than 4 hours
- B. Keep the diaphragm in a cool location
- C. Have the diaphragm resized if she gains 5 pounds
- D. Have the diaphragm resized if she has any surgery
Correct Answer: D
Rationale: Surgery, especially pelvic or abdominal, can alter pelvic anatomy, requiring the diaphragm to be resized for effective contraception.
While terminating the therapeutic nurse-client relationship, which action should be avoided?
- A. raise a new issue with the client
- B. review accomplishments of the relationship
- C. refer the client to a community support group
- D. allow the client to express his feelings about ending the relationship
Correct Answer: A
Rationale: Raising a new issue at termination can disrupt closure and hinder the client’s ability to process the end of the relationship.
The physician has prescribed NPH insulin for a client with diabetes mellitus. Which statement indicates that the client knows when the peak action of the insulin occurs?
- A. I will make sure I eat breakfast within 2 hours of taking my insulin.
- B. I will need to carry candy or some form of sugar with me all the time.
- C. I will eat a snack around three o'clock each afternoon.
- D. I can save my dessert from supper for a bedtime snack.
Correct Answer: C
Rationale: NPH insulin peaks 4-12 hours after administration, so a snack around 3 PM helps prevent hypoglycemia during peak action.
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.