Nokea
Which of the following respiratory patterns indicates increasing intracranial pressure in the brain stem?
- A. Slow, irregular respirations.
- B. Rapid, shallow respirations.
- C. Asymmetric chest excursion.
- D. Nasal flaring.
Correct Answer: A
Rationale: Slow, irregular respirations (e.g., Cheyne-Stokes or ataxic breathing) are indicative of brain stem dysfunction due to increasing intracranial pressure. Rapid, shallow respirations may indicate hypoxia, asymmetric chest excursion suggests mechanical issues, and nasal flaring is associated with respiratory distress, not specifically ICP.
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Which of the following individuals should the nurse consider to have the highest priority for receiving seasonal influenza vaccination?
- A. A 60-year-old man with a hiatal hernia.
- B. A 36-year-old woman with three children.
- C. A 50-year-old woman caring for a spouse with cancer.
- D. A 60-year-old woman with osteoarthritis.
Correct Answer: C
Rationale: The 50-year-old caring for an immunocompromised spouse is the highest priority for influenza vaccination to prevent transmission. Others have lower risk profiles.
A client is undergoing a bone marrow aspiration and biopsy. What is the best way for the nurse to help the client handle her stress?
- A. Allow the client's family to stay with her as long as possible.
- B. Stay with the client and hold her hand without speaking.
- C. Encourage the client to take slow, deep breaths.
- D. Allow the client time to express her feelings.
Correct Answer: C
Rationale: Encouraging slow, deep breaths helps reduce anxiety and promotes relaxation during the stressful bone marrow aspiration procedure. Family presence, hand-holding, and expressing feelings are supportive but less effective for immediate stress management.
What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
A client with a family history of cancer asks the nurse what the single most important risk factor is for cancer. Which of the following risk factors should be necessary:
- A. Family history.
- B. Lifestyle choices.
- C. Age.
- D. Menopause or hormonal events.
Correct Answer: C
Rationale: Age is the most significant risk factor for cancer, as the incidence of most cancers increases with advancing age due to cumulative genetic and environmental damage.
A client's bone marrow report reveals normal stem cells and precursors of platelets (megakaryocytes) in the presence of decreased circulating platelets. The nurse recognizes a knowledge deficit when the client makes which of the following statements?
- A. I need to stop flossing and throw away my hard toothbrush.'
- B. I am glad that my report turned out normal.'
- C. Now I know why I have all these bruises.'
- D. I shouldn't jump off that last step anymore.'
Correct Answer: B
Rationale: Normal stem cells and megakaryocytes with decreased circulating platelets suggest a peripheral destruction issue, such as ITP, not a bone marrow production problem. The client's statement that the report is 'normal' indicates a misunderstanding, as the low platelet count is abnormal and requires management. The other statements reflect appropriate awareness of bleeding risks.