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Which signs/symptoms would be considered classical signs of meningeal irritation?
- A. Positive Kernig sign, diarrhea, and headache
- B. Negative Brudzinski sign, positive Kernig sign, and irritability
- C. Positive Brudzinski sign, positive Kernig sign, and photophobia
- D. Negative Kernig sign, vomiting, and fever
Correct Answer: C
Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.
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A male client with muscular dystrophy fell in his home and is admitted with a right hip fracture. His right foot is cool, with palpable pedal pulses. Lungs are coarse with diminished bibasilar breath sounds. Vital signs are temperature 101 degrees F, heart rate 128 beats/minute, respirations 28 breaths/minute, and blood pressure 122/82. Which intervention is most important for the nurse to implement first?
- A. Obtain oxygen saturation level.
- B. Encourage incentive spirometry.
- C. Assess lower extremity circulation
- D. Administer PRN oral antipyretic.
Correct Answer: D
Rationale: Administering an antipyretic is the most important intervention. The client presents with an elevated temperature, tachycardia, and tachypnea, indicating a fever. Lowering the temperature with an antipyretic is crucial to prevent complications like dehydration, altered mental status, and increased oxygen demand. While assessing lower extremity circulation and oxygen saturation are important, addressing the elevated temperature takes priority in this scenario. Incentive spirometry may be beneficial but is not the priority compared to managing the fever.
The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?
- A. Flush the tube with 50 mL of normal saline every 8 hours
- B. Clamp the tube when not in use
- C. Position the client in a supine position
- D. Verify tube placement by checking pH of gastric contents
Correct Answer: D
Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.
Which nursing diagnosis should be selected for a client who is receiving thrombolytic infusions for treatment of an acute myocardial infarction?
- A. Risk for infection related to thrombolysis.
- B. Risk for fluid volume deficit related to thrombolysis.
- C. Risk for impaired skin integrity related to thrombolysis.
- D. Risk for injury related to effects of thrombolysis.
Correct Answer: D
Rationale: Thrombolytic therapy increases the risk of bleeding, not infection, fluid volume deficit, or impaired skin integrity. The most significant concern with thrombolytic therapy is the potential for bleeding complications, which can lead to various injuries. Therefore, 'Risk for injury related to effects of thrombolysis' is the most appropriate nursing diagnosis in this scenario. Choices A, B, and C are incorrect as they do not directly correlate with the primary risk associated with thrombolytic therapy.
A client with ulcerative colitis is experiencing frequent diarrhea. What is the priority nursing diagnosis?
- A. Risk for impaired skin integrity
- B. Fluid volume deficit
- C. Imbalanced nutrition: less than body requirements
- D. Activity intolerance
Correct Answer: B
Rationale: The correct answer is B: Fluid volume deficit. In a client with ulcerative colitis experiencing frequent diarrhea, the priority nursing diagnosis is addressing the potential fluid volume deficit due to significant fluid loss. Maintaining adequate hydration is crucial to prevent complications associated with dehydration. While choices A, C, and D can also be concerns for a client with ulcerative colitis, addressing fluid volume deficit takes precedence as it directly impacts the client's physiological stability and can lead to serious complications if not managed promptly.
During a paracentesis, two liters of fluid are removed from the abdomen of a client with ascites. A drainage bag is placed, and 50 ml of straw-colored fluid drains within the first hour. What action should the nurse implement?
- A. Palpate for abdominal distention
- B. Send fluid to the lab for analysis
- C. Continue to monitor the fluid output
- D. Clamp the drainage tube for 5 minutes
Correct Answer: C
Rationale: Continuing to monitor the fluid output is the appropriate action in this situation. Monitoring the fluid output helps the nurse assess the client's ongoing response to the procedure and detect any sudden changes, such as increased or decreased drainage rate, which could indicate complications. Palpating for abdominal distention, sending fluid to the lab for analysis, or clamping the drainage tube are not necessary actions at this point, as the priority is to monitor the client's condition post-procedure.