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Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
- A. Nausea and vomiting
- B. Headache
- C. Dizziness
- D. Papilledema
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.
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The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states
- A. I will massage my legs three times a day.
- B. I will elevate the foot of my bed on blocks.
- C. I will take a brisk walk for 20 minutes each day.
- D. I will prop my feet up when I sit to watch TV.
Correct Answer: C
Rationale: Answer C is the 'odd answer' and correct. Walking improves circulation by developing muscles that support blood vessels. Massaging may dislodge clots, elevating the bed is not specific to circulation, and propping feet reduces venous pooling but is less effective than walking.
A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
- A. Irrigate the wound and then apply a dry dressing and cover with a wet compress.
- B. Apply a wet dressing for two hours followed by a dry dressing for two hours.
- C. Apply a wet dressing, and cover with a dry dressing.
- D. Apply a wet dressing above the wound and a dry dressing below the wound.
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.
The nurse is teaching testicular self-exam to a group of young men. Which information should be included in the instructions? Select all that apply.
- A. Perform the exam once a week.
- B. Palpate each testicle between the thumb and forefinger.
- C. Palpate the spermatic cord.
- D. Look in the mirror for dimpling.
- E. Testicles should be the same size.
- F. Both testicles should be at the same level.
Correct Answer: B,C
Rationale: Palpating the testicle and spermatic cord detects lumps or abnormalities during testicular self-exam. Monthly (not weekly) exams are recommended, dimpling is for breast exams, and testicles may differ slightly in size and level.
A client develops orthopnea, dyspnea, and basilar crackles.
Which of the following nursing actions would be MOST appropriate for this client?
- A. Elevate the legs to promote venous return.
- B. Decrease the IV fluids and notify the physician.
- C. Orient the client to time, place, and situation.
- D. Prevent complications of immobility.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would worsen the situation (2) correct-orthopnea, dyspnea, and crackles are signs and symptoms of fluid excess; decreasing the IV fluids is the priority (3) not of priority in this situation (4) not of priority in this situation
The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report dizziness or lightheadedness.
- C. Stop the medication if symptoms improve.
- D. Avoid checking pulse rate.
Correct Answer: B
Rationale: Dizziness or lightheadedness may indicate hypotension, a carvedilol side effect, requiring reporting. Options A, C, and D are incorrect.