Nokea
Which situations would prompt the health care team to use the client’s advance directive to make a decision regarding care? Select all that apply.
- A. Client diagnosed with lumbar spinal cord compression has paraplegia
- B. Client’s Glasgow Coma Scale (GCS) score is 3
- C. Client is refusing a life-saving treatment due to religious beliefs
- D. Client with intracerebral hemorrhage has aphasia
- E. Oriented client has cancer and is on a ventilator
Correct Answer: B,D
Rationale: Advance directives guide care when clients cannot communicate decisions, as with a GCS of 3 (unconscious) or aphasia from hemorrhage. Paraplegia, religious refusal, and ventilator use in an oriented client do not impair decision-making capacity.
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A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?
- A. BP 120/80, pulse 120, respirations 20
- B. BP 180/98, pulse 50, temperature 102°F
- C. BP 98/60, pulse 132, temperature 97.6°F
- D. BP 170/90, pulse 80, respirations 24
Correct Answer: B
Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.
The nurse is reinforcing teaching with a client who has a new prescription for sublingual nitroglycerin. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I am able to take nitroglycerin with my prescribed vardenafil
- B. I will stop taking nitroglycerin if I experience a headache or flushing
- C. I can keep a few nitroglycerin tablets in a plastic bag in case I need them while I am away from home
- D. I should take 1 nitroglycerin tablet every 5 minutes, up to 3 doses, if I am experiencing chest pain
Correct Answer: D
Rationale: Many clients lack knowledge about the proper administration, storage, and side effects of nitroglycerin (NTG). Client teaching can prevent many emergency department visits for chest pain caused by stable angina. Clients should be taught to take 1 tablet every 5 minutes, up to 3 doses. Emergency medical services should be called if pain does not improve or worsens 5 minutes after the first tablet is taken. Previously, clients were taught to call after the third dose was taken, but new evidence suggests this causes a significant delay in treatment
The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?
- A. Anticipate the use of clean technique during the circumcision
- B. Apply a snug-fitting diaper following the procedure
- C. Offer a bottle during the procedure
- D. Wrap the newborn’s upper body in a blanket for the circumcision
Correct Answer: D
Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.
The nurse is assessing for jaundice in a client who has dark skin. What is the best way to do this?
- A. Ask the client if his/her stool has changed color
- B. Look at the client's sclera
- C. Pinch the nail beds and observe the color
- D. Look at the client's fingers
Correct Answer: B
Rationale: The sclera (white of the eyes) reliably shows yellowing in jaundice, even in dark skin, unlike stool color, nail beds, or fingers, which are less specific.
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
- A. Administer PRN analgesic medication
- B. Administer PRN antihypertensive medication
- C. Lower the head of the bed
- D. Palpate the client’s bladder
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.