Nokea
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
- A. Gradual increase
- B. Widening pulse pressure
- C. Rapid drop followed by gradual increase
- D. Rapid fluctuations
Correct Answer: B
Rationale: The correct answer is B, Widening pulse pressure. This indicates increasing intracranial pressure (ICP) as it signifies a significant difference between systolic and diastolic blood pressure. A widening pulse pressure is a key sign of impending herniation and requires immediate intervention.
A: Gradual increase does not provide a clear indication of acute changes in ICP.
C: Rapid drop followed by gradual increase may suggest other conditions and is not specific to increasing ICP.
D: Rapid fluctuations may occur in various scenarios and do not specifically point to increasing ICP.
In summary, a widening pulse pressure is the most critical and specific indicator of increasing ICP among the choices provided.
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The nurse is assigned to care for a postoperative client who has diabetes mellitus. During the assessment interview, the client reports that he’s impotent and says he’s concerned about its effect on his marriage. In planning this client’s care, the most appropriate intervention would be to:
- A. Encourage the client to ask questions about personality sexuality
- B. Provide time for privacy
- C. Provide support for the spouse or significant other
- D. Suggest referral to a sex counselor or other appropriate professional
Correct Answer: D
Rationale: The correct answer is D: Suggest referral to a sex counselor or other appropriate professional. This is the most appropriate intervention as it addresses the client's concern about impotence affecting his marriage by offering specialized help from a professional who can provide counseling and guidance on managing sexual issues related to diabetes. Referring the client to a sex counselor ensures that he receives expert support in addressing his specific concerns and helps improve his overall well-being and quality of life.
A: Encouraging the client to ask questions about personality sexuality may not address the underlying issue of impotence and its impact on the marriage.
B: Providing time for privacy is important but may not directly address the client's concerns about impotence.
C: Providing support for the spouse or significant other is beneficial, but the primary focus should be on addressing the client's specific concerns about impotence.
The client with rheumatoid arthritis reports GI irritation after taking piroxicam (Feldene). To prevent GI upset, the nurse should provide which instruction?
- A. Space the administration every 4
- B. Use the drug for a short time only
- C. Decrease the piroxicam dosage
- D. Take piroxicam with food or oral antacid
Correct Answer: D
Rationale: The correct answer is D. Taking piroxicam with food or an oral antacid can help reduce GI irritation as it can protect the stomach lining. Piroxicam is known to cause GI upset due to its effects on prostaglandin synthesis. Spacing the administration every 4 hours (choice A) may not necessarily prevent GI upset. Using the drug for a short time only (choice B) may not address the immediate concern of GI irritation. Decreasing the piroxicam dosage (choice C) may not be necessary if taking it with food or an antacid can effectively alleviate the GI upset.
Pulmonary edema is characterized by:
- A. Elevated left ventricular and-diastolic
- B. Increased hydrostatic pressure
- C. All of the above alterations
- D. A rise in pulmonary venous pressure
Correct Answer: C
Rationale: Rationale:
1. Pulmonary edema is caused by increased hydrostatic pressure in the pulmonary circulation.
2. Elevated left ventricular end-diastolic pressure signifies heart failure, a common cause of pulmonary edema.
3. A rise in pulmonary venous pressure is a consequence of increased hydrostatic pressure.
Therefore, all three alterations (A, B, D) are characteristic of pulmonary edema. Option C is correct. Choices A, B, and D are incorrect because they are all individually associated with pulmonary edema and collectively represent the condition.
Which iron-rich foods should the nurse encourage an anemic client requiring iron therapy to eat?
- A. Shrimp and tomatoes
- B. Cheese and bananas
- C. Lobster and squash
- D. Lamb and peaches
Correct Answer: A
Rationale: The correct answer is A: Shrimp and tomatoes. Shrimp is a good source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Tomatoes are rich in Vitamin C, which helps enhance iron absorption. Cheese, bananas, lobster, squash, lamb, and peaches do not provide significant amounts of iron essential for an anemic client. The combination of shrimp and tomatoes offers a balanced approach to increase iron levels effectively.
A client with rheumatoid arthritis is being discharged with a prescription for aspirin (Ecotrin), 600mg PO every 6 hours. The nurse should instruct the client to notify the physician if which adverse drug reaction occurs?
- A. Dysuria
- B. Tinnitus
- C. Leg cramps
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Tinnitus. Aspirin can cause tinnitus (ringing in the ears) as an adverse drug reaction, which can indicate potential ototoxicity. Tinnitus is an important side effect that should be reported promptly to the physician to prevent further auditory complications. Dysuria (A), leg cramps (C), and constipation (D) are not typically associated with aspirin use and are less urgent compared to tinnitus. Reporting these side effects may still be necessary but are not as critical as tinnitus in this scenario.