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.
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The nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone
- B. Observe for swelling of the neck, tracheal deviation, and severe pain
- C. Evaluate the quality of the client’s voice postoperatively, noting any dastric changes
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes
Correct Answer: D
Rationale: The correct answer is D: Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. After a thyroidectomy, the parathyroid glands may be inadvertently damaged, leading to hypocalcemia. Muscle twitching and numbness/tingling are early signs of hypocalcemia. The nurse should monitor for these symptoms to detect and address hypocalcemia promptly.
Choice A is incorrect as monitoring thyroid-stimulating hormone levels is not related to hypocalcemia. Choice B is incorrect as it describes signs of potential complications like bleeding or airway obstruction, not hypocalcemia. Choice C is incorrect as changes in voice quality and gastric issues are not specific to hypocalcemia.
A 17-year-old student enters the emergency department with a nosebleed that won’t quit. Which of the following positions is recommended for the patient with a nosebleed?
- A. Lying down with feet elevated
- B. Sitting up with neck extended
- C. Lying down with a small pillow under the head
- D. Sitting up leaning slightly forward
Correct Answer: D
Rationale: The correct answer is D: Sitting up leaning slightly forward. This position helps prevent blood from flowing back into the throat, reducing the risk of choking and aspiration. It also allows for better drainage of blood out of the nose. Lying down with feet elevated (choice A) can increase blood flow to the head and worsen the nosebleed. Sitting up with neck extended (choice B) can lead to blood flowing into the throat. Lying down with a small pillow under the head (choice C) may cause blood to flow backward.
Five girls were victims of wasp and bee bites. Emergency treatment for these includes:
- A. A poultice of sodium bicarbonate and water may give relief
- B. A weak solution of household ammonia also decreases pain and is safe to use
- C. A and B are correct
- D. None of these
Correct Answer: A
Rationale: The correct answer is A because a poultice of sodium bicarbonate and water can help neutralize the venom and reduce pain from wasp and bee bites. Sodium bicarbonate has alkaline properties that can counteract the acidic venom. Option B is incorrect as household ammonia can cause skin irritation and should not be applied to insect bites. Option C is incorrect because only option A is a safe and effective treatment for wasp and bee bites. Option D is incorrect as there is a suitable emergency treatment available.
Which of the following terms would indicate to the nurse that a substance is toxic to the ear?
- A. Otoplasty
- B. Ototoxic
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Ototoxic. Ototoxic refers to substances that are harmful to the ear, potentially causing hearing loss or damage. The prefix "oto-" specifically relates to the ear. Otoplasty (A) is a surgical procedure to reshape the ear, not related to toxicity. Otalgia (C) refers to ear pain, not toxicity. Tinnitus (D) is a symptom of ringing in the ears, not directly related to toxicity. Therefore, the term "ototoxic" is the best indicator of a substance being toxic to the ear due to its specific reference to ear toxicity.
What should a male client over age 50 do to help ensure early identification of prostate cancer?
- A. Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
- B. Have a transrectal ultrasound every 5 years
- C. Perform monthly testicular self-examinations, especially after age 50
- D. Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
Correct Answer: A
Rationale: The correct answer is A: Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly. This is because regular screening with both tests can help detect prostate cancer early. The digital rectal exam allows the doctor to feel for any abnormalities in the prostate gland, while the PSA test measures the levels of a specific protein produced by the prostate gland. If there are any concerning findings, further diagnostic tests can be done to confirm prostate cancer.
Choice B is incorrect because transrectal ultrasound is not a recommended screening test for prostate cancer. Choice C is incorrect as testicular self-examinations are for detecting testicular cancer, not prostate cancer. Choice D is incorrect as CBC, BUN, and creatinine levels are not specific tests for prostate cancer screening.