Nokea
Which finding should the nurse identify as a potential indication of increased intracranial pressure?
- A. Increasingly severe headache
- B. Bradycardia and hypertension
- C. Dilated, non-reactive pupils
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, "All of the above." Increasingly severe headache is a common symptom of increased intracranial pressure due to brain tissue compression. Bradycardia and hypertension can occur as a result of increased intracranial pressure affecting the autonomic nervous system. Dilated, non-reactive pupils may indicate brainstem compression. Therefore, all of these findings are potential indications of increased intracranial pressure. Choices A, B, and C all individually point towards different manifestations of increased intracranial pressure, making them incorrect if considered in isolation.
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Select the 2 findings that require immediate follow-up.
- A. Blood pressure
- B. Duration of contraction
- C. Fetal heart rate
- D. Fetal station
- E. Characteristics of amniotic fluid
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B
- C. Metoclopramide
- D. Vitamin K
Correct Answer: B
Rationale: The correct answer is B: Vitamin B. The nurse should instruct the client about Vitamin B because it plays a crucial role in various bodily functions such as energy production, nerve function, and red blood cell formation. Deficiency in Vitamin B can lead to various health issues. Ranitidine, Metoclopramide, and Vitamin K are specific medications that are not typically instructed by nurses unless prescribed by a healthcare provider for specific conditions. Vitamin K is essential for blood clotting, but its education is usually provided by healthcare providers for specific cases.
Which of the following manifestations should the nurse expect?
- A. Fever
- B. Bradycardia
- C. Dry skin
- D. Decreased respiratory rate
Correct Answer: A
Rationale: The correct answer is A: Fever. When the body is fighting an infection or inflammation, fever is a common manifestation due to the release of pyrogens that reset the body's temperature. Bradycardia (B) is a slow heart rate, not typically associated with infection. Dry skin (C) is more indicative of dehydration or a skin condition. Decreased respiratory rate (D) is not a common manifestation of infection. In this case, fever is the most expected manifestation due to the body's response to an infection.
Which action should the nurse take?
- A. Apply direct pressure to the wound with thick dressing material.
- B. Elevate the affected leg above heart level and apply light dressing.
- C. Apply a tourniquet immediately above the wound site.
- D. Apply ice packs to the wound to slow the bleeding.
Correct Answer: A
Rationale: The correct answer is A. Applying direct pressure to the wound with thick dressing material is the most appropriate action to control bleeding. It helps to compress the blood vessels, slowing down the bleeding. Elevating the leg (choice B) may not be enough to stop severe bleeding. Applying a tourniquet (choice C) should only be done as a last resort for life-threatening bleeding as it can lead to tissue damage. Applying ice packs (choice D) constricts blood vessels, potentially trapping harmful substances in the wound. It is crucial to address the immediate bleeding before considering other actions.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Anticipate administering prescribed immunosuppressant medications
- B. Ensure that client has intake of at least 200 ml/hr
- C. Encourage client to avoid direst sunlight
- D. Initiate contact precautions
- E. Prepare client for light therapy
- F. Sickle cell crisis
- G. Psoriasis
Correct Answer: B,E
Rationale: Systemic lupus erythematosus is indicated by the lab results and symptoms.