A 10-year-old who has sustained a head injury is brought to the emergency
department by his mother. A diagnosis of a mild concussion is made. At the
time of discharge, nurse Ron should instruct the mother to:
1. Withh
...
A 10-year-old who has sustained a head injury is brought to the emergency
department by his mother. A diagnosis of a mild concussion is made. At the
time of discharge, nurse Ron should instruct the mother to:
1. Withhold food and fluids for 24 hours.
2. Allow him to play outdoors with his friends.
3. Arrange for a follow up visit with the child’s primary care provider in one
week.
4. Check for any change in responsiveness every two hours until the
follow-up visit.
Answer
Check for any change in responsiveness every two hours until the follow-up
visit. Signs of an epidural hematoma in children usually do not appear for 24
hours or more hours; a follow-up visit usually is arranged for one to two days
after the injury.
A male client has suffered a motor accident and is now suffering from
hypovolemic shock. Nurse Helen should frequency assess the client’s vital
signs during the compensatory stage of shock, because:
1. Arteriolar constriction occurs
2. The cardiac workload decreases
3. Decreased contractility of the heart occurs
4. The parasympathetic nervous system is triggered
Answer
Arteriolar constriction occurs. The early compensation of shock is
cardiovascular and is seen in changes in pulse, BP, and pulse pressure; blood is
shunted to vital centers, particularly heart and brain.
A paranoid male client with schizophrenia is losing weight, reluctant to eat,
and voicing concerns about being poisoned. The best intervention by nurse
Dina would be to:
1. Allow the client to open canned or pre-packaged food
2. Restrict the client to his room until 2 lbs are gained
3. Have a staff member personally taste all of the client’s food
4. Tell the client the food has been x-rayed by the staff and is safe
Answer
Allow the client to open canned or pre-packaged food. The client’s comfort,
safety, and nutritional status are the priorities; the client may feel comfortable
to eat if the food has been sealed before reaching the mental health facility.
One day the mother of a young adult confides to nurse Frida that she is very
troubled by he child’s emotional illness. The nurse’s most therapeutic initial
response would be:
1. “You may be able to lessen your feelings of guilt by seeking counseling”
2. “It would be helpful if you become involved in volunteer work at this
time”
3. “I recognize it’s hard to deal with this, but try to remember that this too
shall pass”
4. “Joining a support group of parents who are coping with this problem
can be quite helpful.
Answer
“Joining a support group of parents who are coping with this problem can be
quite helpful. Taking with others in similar circumstances provides support and
allows for sharing of experiences.
To check for wound hemorrhage after a client has had a surgery for the
removal of a tumor in the neck, nurse grace should:
1. Loosen an edge of the dressing and lift it to see the wound
2. Observe the dressing at the back of the neck for the presence of blood
3. Outline the blood as it appears on the dressing to observe any
progression
4. Press gently around the incision to express accumulated blood from the
wound
Answer
Observe the dressing at the back of the neck for the presence of blood.
Drainage flows by gravity.
A 16-year-old primigravida arrives at the labor and birthing unit in her 38th
week of gestation and states that she is labor. To verify that the client is in true
labor nurse Trina should:
1. Obtain sides for a fern test
2. Time any uterine contractions
3. Prepare her for a pelvic examination
4. Apply nitrazine paper to moist vaginal tissue
Answer
Prepare her for a pelvic examination. Pelvic examination would reveal dilation
and effacement
As part of the diagnostic workup for pulmonic stenosis, a child has cardiac
catheterization. Nurse Julius is aware that children with pulmonic stenosis have
increased pressure:
1. In the pulmonary vein
2. In the pulmonary artery
3. On the left side of the heart
4. On the right side of the heart
Answer
On the right side of the heart. Pulmonic stenosis increases resistance to blood
flow, causing right ventricular hypertrophy; with right ventricular failure there
is an increase in pressure on the right side of the heart.
An obese client asks nurse Julius how to lose weight. Before answering, the
nurse should remember that long-term weight loss occurs best when:
1. Eating patterns are altered
2. Fats are limited in the diet
3. Carbohydrates are regulated
4. Exercise is a major component
Answer
Eating patterns are altered. A new dietary regimen, with a balance of foods
from the food pyramid, must be established and continued for weight
reduction to occur and be maintained.
As a very anxious female client is talking to the nurse May, she starts crying.
She appears to be upset that she cannot control her crying. The most
appropriate response by the nurse would be:
1. “Is talking about your problem upsetting you?”
2. “It is Ok to cry; I’ll just stay with you for now”
3. “You look upset; lets talk about why you are crying.”
4. “Sometimes it helps to get it out of your system.”
Answer
“It is ok to cry; I’ll just stay with you for now” This portrays a nonjudgmental
attitude that recognizes the client’s needs.
A patient has partial-thickness burns to both legs and portions of his trunk.
Which of the following I.V. fluids is given first?
1. Albumin
2. D5W
3. Lactated Ringer’s solution
4. 0.9% sodium chloride solution with 2 mEq of potassium per 100 ml
Answer
Lactated Ringer’s solution. Lactated Ringer’s solution replaces lost sodium and
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