Nokea
Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed is the correct answer because it helps to promote venous drainage, reduce cerebral edema, and decrease intracranial pressure (ICP). By positioning the patient with the head elevated, gravity assists in preventing further increases in ICP. Encouraging fluids may lead to fluid overload and exacerbate cerebral edema. Providing physical therapy and frequent repositioning may increase ICP by causing unnecessary movement and potential strain on the patient's head and neck.
You may also like to solve these questions
A client has squamous cell cancer of the right lung that has metastasized to the brain. In addition to chemotherapy for lung cancer, the physician prescribes lomustine (CeeNU), 100 mg/m2 as a single dose, to treat the brain metastasis. What are the major administration and excretion routes of lomustine?
- A. Oral administration and urinary
- B. I.V. administration and urinary excretion
- C. I.V administration and fecal excretion
- D. Oral administration and fecal excretion
Correct Answer: B
Rationale: The correct answer is B: I.V. administration and urinary excretion. Lomustine is typically administered intravenously, allowing for rapid systemic distribution. The drug is metabolized in the liver and excreted primarily through the kidneys, thus the urinary route. This choice is correct as lomustine's pharmacokinetics align with this pattern.
A: Oral administration and urinary - While some drugs are administered orally, lomustine is not typically given orally due to poor bioavailability.
C: I.V. administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.
D: Oral administration and fecal excretion - Lomustine is not primarily excreted via the feces, making this choice incorrect.
If a client’s parathyroid glands were accidentally removed during a procedure, which condition should the nurse prepare for?
- A. Hypomagnesemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypocalcemia
Correct Answer: D
Rationale: The correct answer is D: Hypocalcemia. The parathyroid glands regulate calcium levels in the body. Without them, calcium levels will drop, leading to hypocalcemia. A: Hypomagnesemia is incorrect because magnesium levels are not directly regulated by the parathyroid glands. B: Hyperkalemia and C: Hypernatremia are incorrect as they are not typically associated with parathyroid gland removal. In summary, the removal of parathyroid glands would result in hypocalcemia due to the disruption of calcium regulation in the body.
Bacterial meningitis alters intracranial physiology, causing:
- A. Cerebral edema
- B. Raised intracranial pressure
- C. Increased permeability of the blood-barrier
- D. All of the above changes
Correct Answer: D
Rationale: The correct answer is D. Bacterial meningitis alters intracranial physiology by causing cerebral edema, raised intracranial pressure, and increased permeability of the blood-brain barrier. Cerebral edema is the accumulation of fluid in the brain tissue, leading to increased pressure. Raised intracranial pressure occurs due to the inflammation and swelling caused by the infection. Increased permeability of the blood-brain barrier allows substances to pass through that would normally be blocked, contributing to the inflammatory response. Therefore, all of these changes are interconnected and commonly observed in bacterial meningitis cases. Choices A, B, and C individually describe specific alterations seen in bacterial meningitis but do not encompass the full spectrum of changes that occur, making them incorrect options.
The nurse is assigned to a client with polymyositis. Which expected outcome in the plan of care relates to a potential problem associated with polymyositis?
- A. “Client will lose 2lb per week on a calorie-restricted diet.”
- B. “Client will exhibit no signs or symptoms of aspiration.”
- C. “Client will exhibit bowel and bladder continence.”
- D. “Client will exhibit alertness and orientation to person, place, and time.” DISTURBANCES IN IMMUNOLOGIC FUNCTIONING
Correct Answer: E
Rationale: I'm sorry, but it seems like the correct answer (E) is missing from the question. Could you please provide the correct answer so that I can provide you with a detailed explanation of why it is correct and summarize why the other choices are incorrect?
The nurse understands that which of the ff. best describes the action of propanolol (Inderal)?
- A. It increases heart rate
- B. It decreases fluid volume
- C. It decreases cardiac output
- D. It increases cardiac contractility
Correct Answer: C
Rationale: Step-by-step rationale:
1. Propranolol is a beta-blocker that acts on the heart.
2. It blocks beta-adrenergic receptors, leading to decreased heart rate and contractility.
3. Decreased heart rate and contractility result in reduced cardiac output.
4. Therefore, the correct answer is C - It decreases cardiac output.
Summary: A, B, and D are incorrect because propranolol does not increase heart rate, fluid volume, or cardiac contractility.