Nokea
Which person is at greatest risk for developing Lyme's disease?
- A. Computer programmer
- B. Elementary teacher
- C. Veterinarian
- D. Landscaper
Correct Answer: D
Rationale: Landscapers are at higher risk for Lyme disease due to frequent exposure to tick-infested outdoor environments, where the disease is transmitted.
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An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
A client is admitted for an CAT scan. The nurse should question the client regarding:
- A. Pregnancy
- B. A titanium hip replacement
- C. Allergies to antibiotics
- D. Inability to move his feet
Correct Answer: A
Rationale: Pregnancy is a contraindication for a CAT scan due to radiation risks to the fetus.
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
The nurse is assisting the physician with removalCus of a central venous catheter. To facilitate removal, the nurse should instruct the client to:
- A. Perform the Valsalva maneuver as the catheter is advanced
- B. Turn his head to the left side and hyperextend the neck
- C. Take slow, deep breaths as the catheter is removed
- D. Turn his head to the right while maintaining a sniffing position
Correct Answer: C
Rationale: Taking slow, deep breaths during central venous catheter removal minimizes the risk of air embolism.
A client has orders for placing a small-bore nasoenteric tube. Which finding in the health history would prompt the nurse to notify the prescriber before placing tube?
- A. small-bowel lesion
- B. basilar skull fracture
- C. acute coronary syndrome
- D. use of diabetic insulin pump
Correct Answer: B
Rationale: A basilar skull fracture is a contraindication for nasoenteric tube placement due to the risk of intracranial insertion. Other conditions are not absolute contraindications.