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Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?
- A. Deep breathing.
- B. Turning.
- C. Coughing.
- D. Passive range-of-motion (ROM) exercises.
Correct Answer: C
Rationale: Coughing increases intrathoracic pressure, which can elevate ICP. Deep breathing, turning, and passive ROM are generally safe and may even help prevent complications like atelectasis or contractures if done gently.
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Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply.
- A. A local anesthetic agent may be injected into the joint site for your comfort.'
- B. A syringe and needle will be used to withdraw fluid from your joint.'
- C. The procedure, although not painful, will provide immediate relief.'
- D. We'll want you to keep your joint active after the procedure to increase blood flow.'
- E. You will need to wear a compression bandage for several days after the procedure.'
Correct Answer: A,B
Rationale: Arthrocentesis involves using a needle and syringe to withdraw fluid, often with a local anesthetic for comfort. The procedure may be painful, and rest, not activity, is typically recommended post-procedure. A compression bandage is not standard.
A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. The nurse should first:
- A. Ask what medications the client is taking.
- B. Complete a history and health assessment.
- C. Identify the time of onset of the stroke.
- D. Determine if the client is scheduled for any surgical procedures.
Correct Answer: C
Rationale: The time of stroke onset is critical for t-PA administration, as it must be given within a specific window (typically 3-4.5 hours) to be effective and safe. Other assessments follow this priority.
Interferon alfa-2b (Intron A) has been prescribed to treat a client with chronic hepatitis B. The nurse should assess the client for which of the following adverse effects?
- A. Retinopathy.
- B. Constipation.
- C. Flulike symptoms.
- D. Hypoglycemia.
Correct Answer: C
Rationale: Interferon alfa-2b commonly causes flulike symptoms (C), such summer fever, chills, and fatigue. Retinopathy (A), constipation (B), and hypoglycemia (D) are not typical adverse effects.
A client who has had ulcerative colitis for the past 5 years is admitted to the hospital with an exacerbation of the disease. Which of the following factors was most likely of greatest significance in causing an exacerbation of ulcerative colitis?
- A. A demanding job.
- B. Recent travel.
- C. A high-fiber diet.
- D. Stopping corticosteroid therapy.
Correct Answer: D
Rationale: Stopping corticosteroid therapy can lead to an exacerbation of ulcerative colitis, as corticosteroids help control inflammation. A demanding job or recent travel may contribute to stress but are less directly linked. A high-fiber diet is generally beneficial for managing symptoms unless during an acute flare. CN: Physiological adaptation; CL: Analyze
When teaching a client about propranolol hydrochloride, the nurse should base the information on the knowledge that propranolol:
- A. Blocks beta-adrenergic stimulation and thus causes decreased heart rate, myocardial contractility, and conduction.
- B. Increases norepinephrine secretion and thus decreases blood pressure and heart rate.
- C. Is a diuretic that reduces peripheral vascular resistance and lowers blood pressure.
- D. Is an angiotensin-converting enzyme inhibitor that reduces blood pressure by blocking the conversion of angiotensin I to angiotensin II.
Correct Answer: A
Rationale: Propranolol, a beta-blocker, blocks beta-adrenergic receptors, reducing heart rate, contractility, and conduction, lowering blood pressure.