1. An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? a. Reposition the client to avoid neck flexion b. Administer 1 g Mannitol IV as ordered c. Increase the ventilator’s respiratory rate to 20 breaths/minute d. Administer 100mg of pentobarbital IV as ordered. 2. A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? a. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. b. Rapid dilantin administration can cause cardiac arrhythmias. c. Dilantin should be mixed in dextrose in water before administration. d. Dilantin should be administered through an IV catheter in the client’s hand. 3. A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a. Evaluate urine specific gravity b. Anticipate treatment for renal failure c. Provide emollients to the skin to prevent breakdown d. Slow down the IV fluids and notify the physician 4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). b. Emergent; the client is poorly oxygenated. c. Normal d. Significant; the client has alveolar hypoventilation. 5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by...
B. Solitary activities that require a short attention span with mild physical exertion are the most appropriate activities for a client who is exhibiting aggressive behavior. Writing, walks with staff, and finger painting are activities that minimize stimuli and provide a constructive release for tension. Competitive games can stimulate aggression and increase psychomotor activity. D. Change in appetite is one of the major symptoms of depression. Reporting to the psychiatrist and nutritionist is to some degree correct but lacks the method as to how one would increase food intake. D. A depressed person experiences a depressed mood and is often withdrawn. The person also experiences difficulty concentrating, loss of interest or pleasure, low energy, fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide successful experiences in a stimulating yet structured environment. Option 3 is a forceful and absolute approach. D. Feelings of low self-esteem and worthlessness are common symptoms of the depressed client. An effective plan of care to enhance the client’s personal self-esteem is to provide experiences for the client that are challenging but will not be met with failure. Reminders of the client’s past accomplishments or personal successes are ways to interrupt the client’s negative self talk and distorted cognitive view of self. Silence may be interpreted as agreement. Options 1 and 3 give advice and devalue the client’s feelings. A. major depression, recurrent, with psychotic features alerts the nurse that in addition to the criteria that designate the diagnosis of major depression, one also must deal with the client’s psychosis. Psychosis is defined as a state in which a person’s...
1. The nurse is planning activities for a client who has bipolar disorder with aggressive social behavior. Which of the following activities would be most appropriate for this client? a. Ping pong b. Writing c. Chess d. Basketball 2. A client is admitted to the hospital with a diagnosis of major depression, severe, single episode. The nurse assesses the client and identifies a nursing diagnosis of imbalanced nutrition related to poor nutritional intake. The most appropriate nursing intervention related to this diagnosis is: a. Explain to the client the importance of a good nutritional intake b. Weight the client 3 times per week before breakfast c. Report the nutritional concern to the psychiatrist and obtain a nutritional consultation as soon as possible. d. Consult with the nutritionist, offer the client several small meals per day, and schedule brief nursing interactions with the client during these times. 3. In planning activities for the depressed client, especially during the early stages of hospitalization, which of the following plans is best? a. Provide an activity that is quiet and solitary to avoid increased fatigue, such as working on a puzzle or reading a book. b. Plan nothing until the client asks to participate in milieu. c. Offer the client a menu of daily activities and insist the client participate in all of them d. Provide a structured daily program of activities and encourage the client to participate. 4. The depressed client verbalizes feelings of low self-esteem and self-worth typified by statements such as “I’m such a failure… I can’t do anything right!” The best nursing response would be: a. To tell the...
This is a 10-question Quiz in Practice Mode. This will not be scored and will not affect your stats scores, and level. Match the item on the left to the appropriate description on the right. Click on the answer of your choice and drag & drop to its appropriate place.Bulb Syringe Aspirator This is a device with a flexible bulb that replaces the plunger for instillation or aspiration and can be used to irrigate an external orifice, such as the auditory canal. Compression of the bulb creates a vacuum for gentle suction of small amounts of bodily drainage, such as oral and nasal secretions. UnselectThis is used in the measurement of skinfold thickness and the estimation of total body fat. UnselectSkinfold Caliper This is a device with a flexible bulb that replaces the plunger for instillation or aspiration and can be used to irrigate an external orifice, such as the auditory canal. Compression of the bulb creates a vacuum for gentle suction of small amounts of bodily drainage, such as oral and nasal secretions. UnselectThis is used in the measurement of skinfold thickness and the estimation of total body fat. Unselect Match the item on the left to the appropriate description on the right. Click on the answer of your choice and drag & drop to its appropriate place.Penlight This is used by medical practitioners to assess a patient’s hearing. This is most commonly done with two exams called the Weber test and Rinne test, respectively. In Orthopedic testing, this is toned on the suspected bone with fracture and toned progressively closer to suspected area of fracture. If there...
This is a 10-question Quiz in Practice Mode. This will not be scored and will not affect your stats scores, and level. A client who is 41 weeks pregnant is about to undergo a biophysical profile (BPP) to evaluate her fetus’s well-being. The nurse knows that which components are included in a BPP? Select all that apply. Fetal tone Fetal breathing movements Femur length Amniotic fluid volume Biparietal diameter Crown-rump length A client is prescribed lisinopril (Zestril) for treatment of hypertension. He asks a nurse about possible adverse effects. The nurse should teach him about which of the following common adverse effects of angiotensin converting enzyme (ACE) inhibitors? Select all that apply. Constipation Dizziness Headache Hyperglycemia Hypotension Impotence The nurse is explaining the Bill of Rights for psychiatric patients to a client who has voluntarily sought admission to an inpatient psychiatric facility. Which of the following rights should the nurse include in the discussion? Select all that apply. Right to select health care team members Right to refuse treatment Right to a written treatment plan Right to obtain disability Right to confidentiality Right to personal mail A woman who is 15 weeks pregnant comes to the clinic for amniocentesis. The nurse knows that this test can be used to identify which characteristics or problems? Select all that apply. Fetal lung maturity Gestational diabetes Chromosomal defects Neural tube defects Polyhydramnios Sex of the fetus The nurse is assisting in the discharge planning for a client with alcoholism. Which of the following should be included in the discharge plan? Select all that apply. Strongly encourage participation in Alcoholics Anonymous (AA). Provide nutritional information and counseling. Establish an exercise program. Discuss relapse prevention. Have the client introduce himself slowly to people from his former lifestyle. The nurse is preparing a female...
This is a 10-question Quiz in Practice Mode. This will not be scored and will not affect your stats scores, and level. 5. from mechanical obstruction is the leading cause of death (by suffocation) for infants younger than 1 year of age. To achieve postural drainage in an infant, place a on the nurse’s lap and lay the infant across it. 8. In the therapeutic environment, the patient’s is the primary concern. 6. are the rumbling sounds heard on lung auscultation. They are more pronounced during expiration than during inspiration. 2. When bottle-feeding a newborn with a cleft palate, hold the infant’s head in an position. 10. pain is pain that incapacitates a patient and can’t be relieved by drugs. 9. For blood transfusion in an adult, the appropriate needle size is to 20G. 3. The most adequate diet for an infant in the first 6 months of life is 7. is forced feeding, usually through a gastric tube (a tube passed into the stomach through the mouth). 4. An infant can usually chew food by months, hold spoon by months, and drink fluid from a cup by year of...
