Nokea
Which action is contraindicated for a client with a risk of increased ICP?
- A. Elevate head of bed.
- B. Administer mannitol.
- C. Encourage coughing.
- D. Monitor neurological status.
Correct Answer: C
Rationale: Coughing is contraindicated as it increases intracranial pressure.
You may also like to solve these questions
Which of the following activities indicates that the client with cancer is adapting well to body image changes?
- A. The client names his brother as the person to call if he is experiencing suicidal ideation.
- B. The client discusses changes in body structure and function.
- C. The client discusses the date of his return to work.
- D. The client serves as a volunteer in a client-to-client visitation program.
Correct Answer: D
Rationale: Volunteering in a client-to-client program indicates positive adaptation to body image changes, as it reflects confidence and engagement with others despite physical changes.
The nurse should include which of the following instructions when developing a teaching plan for a client who is receiving isoniazid and rifampin (Rifamate) for treatment of tuberculosis?
- A. Take the medication with antacids.
- B. Double the dosage if a drug dose is missed.
- C. Increase intake of dairy products.
- D. Limit alcohol intake.
Correct Answer: D
Rationale: Limiting alcohol intake prevents hepatotoxicity, a risk with isoniazid and rifampin. Antacids may reduce absorption. Doubling doses is dangerous. Dairy intake is unrelated.
In setting goals for a client with advanced liver cancer who has poor nutrition, the nurse determines that which of the following is a realistic desired outcome for the client? The client will:
- A. Have normalized albumin levels.
- B. Return to ideal body weight.
- C. Gain 1 lb every 2 weeks.
- D. Maintain current weight.
Correct Answer: D
Rationale: Maintaining current weight is a realistic goal for a client with advanced liver cancer and poor nutrition, as weight gain or normalized albumin may be unachievable due to disease progression.
The nurse is assessing a client with dark skin for presence of a Stage I pressure ulcer. The nurse should:
- A. Use a fluorescent light source to assess the skin.
- B. L rescued the skin only when the Braden score is above 12.
- C. Look for skin color that is darker than the surrounding tissue.
- D. Avoid touching the skin during inspection.
Correct Answer: C
Rationale: In dark skin, Stage I pressure ulcers appear as darker areas compared to surrounding tissue, due to persistent redness or discoloration.
A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 8:30 a.m. to compare them with the current vital signs at 10:30 p.m. (see chart). What should the nurse do fi rst?
- A. Call the physician for pain medication.
- B. Cover the client with warmed blankets.
- C. Administer oxygen at 4 L/minute.
- D. Increase the I.V. fl uid rate.
Correct Answer: B
Rationale: The client’s body temperature dropped 2.5° F from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s pulse rate, respiratory rate, and blood pressure have compensated according to the client’s hypothermic state and will refl ect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or I.V. fl uids.