Nokea
When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?
- A. Brudzinski's sign
- B. Positive Babinski reflex
- C. Kernig's sign
- D. Both A and C
Correct Answer: D
Rationale: The correct answer is D, Both A and C. Brudzinski's sign and Kernig's sign are both indicative of meningeal irritation. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hip and knee. Kernig's sign is when there is resistance or pain with knee extension after hip flexion. These signs suggest inflammation of the meninges, commonly seen in meningitis. Babinski reflex (choice B) is not specific to meningitis and is related to upper motor neuron dysfunction. Therefore, the correct answer is D as it includes the two most relevant signs for meningeal irritation, while the other choices are not directly associated with this condition.
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The client has a nasogastric (NG) tube and is receiving enteral feedings. What intervention should the nurse implement to prevent complications associated with the NG tube?
- A. Flush the NG tube with water before and after feedings.
- B. Check gastric residual volume every 6 hours.
- C. Keep the head of the bed elevated at 30 degrees.
- D. Replace the NG tube every 24 hours.
Correct Answer: C
Rationale: Correct Answer: C - Keep the head of the bed elevated at 30 degrees.
Rationale:
1. Elevating the head of the bed at 30 degrees helps prevent aspiration by promoting proper drainage of gastric contents.
2. This position reduces the risk of reflux and pulmonary complications in clients with NG tubes.
3. It also helps maintain the proper position of the tube in the stomach, decreasing the likelihood of displacement.
Summary of Other Choices:
A. Flushing the NG tube with water before and after feedings is important for tube patency but does not directly prevent complications associated with the NG tube.
B. Checking gastric residual volume every 6 hours is important to monitor feeding tolerance but does not directly prevent complications related to the NG tube.
D. Replacing the NG tube every 24 hours is not necessary unless there are specific indications such as tube blockage or dislodgment. Regular replacement can increase the risk of complications and is not a standard practice.
The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct Answer: B
Rationale: The correct answer is B: Encourage frequent rest periods. For a client with hyperthyroidism, rest is crucial to conserve energy and support the body's recovery. Hyperthyroidism is characterized by increased metabolic rate, leading to fatigue and weakness. Rest periods help reduce metabolic demands and prevent exhaustion. A high-calorie diet (choice A) may be necessary to support increased metabolism but is not the priority. Restricting fluid intake (choice C) can lead to dehydration, which should be avoided in hyperthyroidism. Administering a stool softener (choice D) is unrelated to managing hyperthyroidism.
A client with a history of hypertension is prescribed lisinopril (Prinivil). Which side effect should the nurse monitor for?
- A. Dry cough.
- B. Weight gain.
- C. Tachycardia.
- D. Hyperglycemia.
Correct Answer: A
Rationale: The correct answer is A: Dry cough. Lisinopril, an ACE inhibitor, commonly causes a dry cough due to the accumulation of bradykinin. This side effect can be bothersome and non-productive. Other choices are incorrect because weight gain is not a common side effect of lisinopril but rather a side effect of some other antihypertensive medications. Tachycardia is not associated with lisinopril; in fact, it can cause bradycardia in some cases. Hyperglycemia is not a common side effect of lisinopril and is more commonly associated with other classes of antihypertensive medications.
A client with coronary artery disease (CAD) is prescribed atorvastatin (Lipitor). Which laboratory value requires immediate intervention?
- A. Total cholesterol of 180 mg/dL.
- B. Low-density lipoprotein (LDL) of 200 mg/dL.
- C. Triglycerides of 150 mg/dL.
- D. High-density lipoprotein (HDL) of 40 mg/dL.
Correct Answer: B
Rationale: The correct answer is B: LDL of 200 mg/dL. Elevated LDL levels are a major risk factor for CAD and require immediate intervention. Atorvastatin (Lipitor) is used to lower LDL levels. High LDL contributes to plaque buildup in arteries.
A: Total cholesterol of 180 mg/dL is within the normal range and doesn't require immediate intervention.
C: Triglycerides of 150 mg/dL are also within the normal range and don't pose an immediate risk.
D: HDL of 40 mg/dL is considered low, but it is not as critical as high LDL levels in the context of CAD.
During the initial assessment of a client with a history of substance abuse admitted for detoxification, which intervention is most important?
- A. Obtain a detailed substance use history.
- B. Establish a trusting nurse-client relationship.
- C. Evaluate the client's physical health status.
- D. Determine the client's readiness for change.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's physical health status. This is crucial during detoxification as substance withdrawal can lead to serious physical health complications such as seizures or cardiac issues. Assessing physical health status allows for prompt intervention if needed. Obtaining a detailed substance use history (A) can provide valuable information but is not immediate priority during initial assessment. Establishing a trusting nurse-client relationship (B) is important but ensuring physical safety comes first. Determining client's readiness for change (D) is important for long-term treatment planning but not as urgent as assessing physical health status.