Nokea
Which of the following actions is the nurse's priority when caring for a client with a head injury?
- A. Monitor the client's airway
- B. Administer pain relief
- C. Perform a CT scan
- D. Monitor intracranial pressure
Correct Answer: A
Rationale: The correct answer is A: Monitor the client's airway. This is the priority because airway management is crucial in ensuring adequate oxygenation and ventilation, which is essential for brain function in a client with a head injury. Maintaining a clear airway takes precedence over other actions such as administering pain relief, performing a CT scan, or monitoring intracranial pressure. While these actions are important, ensuring the client's airway is patent and adequate oxygenation is crucial for preventing further brain injury or complications.
You may also like to solve these questions
Which food should a client with hypercholesterolemia decrease in their diet?
- A. broiled catfish
- B. hamburgers
- C. wheat bread
- D. fresh apples
Correct Answer: B
Rationale: The correct answer is B: hamburgers. Clients with hypercholesterolemia should decrease their intake of foods high in saturated fats, like hamburgers. Saturated fats can raise LDL cholesterol levels. Broiled catfish (A) is a lean protein option, wheat bread (C) is a good source of fiber, and fresh apples (D) are a healthy fruit choice. Hamburgers (B) typically contain high levels of saturated fats from red meat and processed ingredients, making them a less ideal choice for individuals with high cholesterol.
A nurse is providing education to a patient with hypertension. Which of the following lifestyle changes should the nurse prioritize?
- A. Increasing physical activity and reducing salt intake.
- B. Increasing alcohol consumption.
- C. Decreasing physical activity.
- D. Increasing sodium intake.
Correct Answer: A
Rationale: The correct answer is A: Increasing physical activity and reducing salt intake. Firstly, increasing physical activity helps lower blood pressure by improving heart health and circulation. Secondly, reducing salt intake helps decrease fluid retention and lower blood pressure. The other choices are incorrect because B: Increasing alcohol consumption can raise blood pressure, C: Decreasing physical activity is counterproductive, and D: Increasing sodium intake can lead to higher blood pressure due to fluid retention. Prioritizing physical activity and reducing salt intake are evidence-based lifestyle changes to manage hypertension effectively.
Which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it may indicate underlying conditions that need to be addressed before starting hormone therapy to avoid potential risks. Vaginal bleeding could be a sign of endometrial hyperplasia or cancer, which can be exacerbated by hormone therapy. Choices A, B, and C are not contraindications for hormone replacement therapy. Family history of stroke may influence the choice of therapy but not necessarily contraindicate it. Ovaries removed before age 45 and frequent hot flashes/night sweats are common indications for hormone replacement therapy to alleviate symptoms of menopause.
A nurse is caring for a patient who is undergoing treatment for cancer. Which of the following symptoms would most likely indicate the need for palliative care?
- A. Severe pain and nausea.
- B. Uncontrolled symptoms despite treatment.
- C. Psychosocial support needs.
- D. All of the above.
Correct Answer: D
Rationale: The correct answer is D because palliative care aims to improve the quality of life for patients with serious illnesses like cancer. Severe pain and nausea (A) are common symptoms that palliative care helps manage. Uncontrolled symptoms despite treatment (B) indicate the need for specialized palliative care interventions. Psychosocial support needs (C) are also addressed in palliative care to address emotional and social aspects of the patient's well-being. Therefore, all of the above (D) are indicative of the need for palliative care as it focuses on holistic symptom management and support for the patient.
A nurse is caring for a patient with a history of heart failure. The nurse should monitor for signs of which of the following complications?
- A. Hypoglycemia.
- B. Pulmonary edema.
- C. Anemia.
- D. Hypertension.
Correct Answer: B
Rationale: The correct answer is B: Pulmonary edema. In heart failure, the heart is unable to pump effectively, leading to fluid buildup in the lungs causing pulmonary edema. This can result in symptoms such as shortness of breath, coughing, and wheezing. Monitoring for pulmonary edema is crucial in heart failure management to prevent respiratory distress and worsening heart function.
Rationale:
A: Hypoglycemia - While patients with heart failure may be at risk for metabolic abnormalities, hypoglycemia is not a common complication directly related to heart failure.
C: Anemia - Anemia can occur in heart failure due to reduced oxygen-carrying capacity of the blood, but it is not a direct complication that requires immediate monitoring like pulmonary edema.
D: Hypertension - Heart failure is characterized by a reduced ability of the heart to pump blood effectively, leading to decreased cardiac output. Therefore, hypertension is not typically a complication seen in heart failure patients.