Nokea
Which finding should the nurse report as a sign of increased intracranial pressure (ICP)?
- A. While an increasing temperature may be associated with ICP, it may also be due to an infection. It is more important for the nurse to report the widened pulse pressure as a sign of increased ICP.
- B. A widened pulse pressure (increased systolic BP and a decreased diastolic BP) is one of the signs of Cushing's triad and is indicative of ICP.
- C. Bradycardia (not tachycardia) is associated with ICP.
- D. An increased systolic BP (not decreased systolic BP) is another sign of Cushing's triad.
Correct Answer: B
Rationale: Widened pulse pressure is a hallmark of Cushing's triad, indicating increased ICP.
You may also like to solve these questions
The nurse is caring for the client who had a right shoulder replacement. Which data warrant immediate intervention?
- A. The client’s hemoglobin is 8.1 g/dL.
- B. The client’s white blood cell count is 9,000/mm3.
- C. The client’s creatinine level is 0.8 mg/dL.
- D. The client’s potassium level is 4.2 mEq/L.
Correct Answer: A
Rationale: Hemoglobin of 8.1 g/dL indicates significant blood loss, requiring urgent intervention post-shoulder replacement. Other values are normal.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.
The nurse is teaching the client with carpal tunnel syndrome how best to utilize a wrist splint. Which statement is most appropriate for the nurse to include in the teaching?
- A. Leave the splint in place even when bathing.
- B. Wear the splint as tight as can be tolerated.
- C. Remove the splint intermittently throughout the day.
- D. Only wear the splint when doing work that stresses the fingers.
Correct Answer: C
Rationale: C. Although the splint decreases swelling and promotes healing and is necessary in the management of the pain with carpal tunnel syndrome, it should be removed intermittently during the day to exercise the wrist and bathe.
The nurse supervises a nursing assistant who is applying the client's antiembolism stockings. What is the correct technique for applying these stockings?
- A. The nursing assistant applies the stockings before getting the client out of bed.
- B. The nursing assistant applies the stockings just before helping the client do leg exercises.
- C. The nursing assistant applies the stockings after nursing that the client's legs are cool.
- D. The nursing assistant applies the stockings at night before the client's bedtime.
Correct Answer: A
Rationale: Applying antiembolism stockings before the client gets out of bed ensures compression is in place during upright positions when venous pooling is most likely. Applying them later or based on leg temperature is less effective.
Which intervention for bladder emptying should the nurse plan to implement for a 14-year-old with a neurogenic bladder from an SCI with a lower motor neuron lesion?
- A. Intermittent catheterization
- B. Insertion of a retention catheter
- C. Insertion of a suprapubic catheter
- D. Giving an anticholinergic medication
Correct Answer: A
Rationale: Intermittent catheterizationelevation is preferred for neurogenic bladder due to lower motor neuron lesions to prevent urinary retention.