N222 OB/PEDS FINAL
The nurse cares for a client with increased intracranial pressure. Which activities contribute to increased intracranial pressure? (Select all that apply. O 1. A quiet environment. O 2. Hand restraints. O 3. Having a bowel movement. O 4. Listening to soft music. O 5. Watching television.
1) A comfortable, quiet environment will not increase intracranial pressure. 2) CORRECT - Restraints increase agitation, thus increasing intracranial pressure. The client may also pull against a restraint and perform a Valsalva maneuver, which will increase intracranial pressure. 3) CORRECT - If the client performs Valsalva maneuver while having a bowel movement, intracranial pressure will be increased. The nurse should provide stool softeners to the client and ensure the client does not become constipated. 4) Soft music does not increase intracranial pressure and may relax the client. 5) A quiet activity does not increase intracranial pressure.
The nurse cares for a client with increased intracranial pressure. Which activities contribute to increased intracranial pressure? (Select all that apply. O 1. A quiet environment. O 2. Hand restraints. O 3. Having a bowel movement. O 4. Listening to soft music. O 5. Watching television.
1) A comfortable, quiet environment will not increase intracranial pressure. 2) CORRECT - Restraints increase agitation, thus increasing intracranial pressure. The client may also pull against a restraint and perform a Valsalva maneuver, which will increase intracranial pressure. 3) CORRECT - If the client performs Valsalva maneuver while having a bowel movement, intracranial pressure will be increased. The nurse should provide stool softeners to the client and ensure the client does not become constipated. 4) Soft music does not increase intracranial pressure and may relax the client. 5) A quiet activity does not increase intracranial pressure.
A child client is admitted with chronic lead poisoning. Which symptoms does the nurse expect to see? O 1. Anemia, seizures, and learning disabilities. O 2. Tinnitus, confusion, and hyperthermia. O 3. Polvevthemia, hypoactivity, and impaired liver function. O 4. Shortness of breath, dependent edema, and bounding pulse.
1) CORRECT - Anorexia, nausea, vomiting, excess salvation, lead line on the gums, abdominal pain, muscle cramps, kidney failure, encephalopathy, and pain in the joints are symptoms of chronic lead poisoning. Treatment includes removal of the child from the lead source. If the lead level is very high treatment will include chelation.
A child client is admitted with chronic lead poisoning. Which symptoms does the nurse expect to see? O 1. Anemia, seizures, and learning disabilities. O 2. Tinnitus, confusion, and hyperthermia. O 3. Polycythemia, hypoactivity, and impaired liver function. O 4. Shortness of breath, dependent edema, and bounding pulse.
1) CORRECT - Anorexia, nausea, vomiting, excess salvation, lead line on the gums, abdominal pain, muscle cramps, kidney failure, encephalopathy, and pain in the joints are symptoms of chronic lead poisoning. Treatment includes removal of the child from the lead source. If the lead level is very high treatment will include chelation.
The nurse assesses a school-age client diagnosed with hemophilia. Which essential data should the nurse collect first? O 1. The client's ability to perform active range of motion. O 2. The frequency and consistency of bowel movements. O 3. The client's usual intake of iron-rich foods. O 4. Presence of multiple petechiae on the lower extremities.
1) CORRECT - As the child moves the joints, the range of motion will be limited by pain from hemorrhage within the joint cavities. This is usually seen in the knees, elbows, and ankles. Gentle passive range of motion exercises can be done to maintain optimal physical mobility if the client's condition is stable.
The nurse assesses for signs associated with increased intracranial pressure in client diagnosed with a subdural hematoma. Which is the earliest sign of an increase in intracranial pressure? O A change in level of consciousness. O A widening pulse pressure. O Bradycardia. O Decorticate position.
1) CORRECT - Change in the level of consciousness is the earliest sign of an increase in intracranial pressure. The cranium is a closed cavity and an increase in pressure causes shifting of brain. Causes of increased intracranial pressure include bleeding, tumors, and edema. Indications include change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia (double vision). Treatment includes osmotic diuretics, furosemide, steroids, antihypertensives, anticonvulsants, hyperventilation, and surgery for decompression or shunt. Nursing care includes maintaining airway by suctioning, elevating head of bed 30 degrees, keeping head in the midline position, and administering fluids.
The nurse assesses for signs associated with increased intracranial pressure in a client diagnosed with a subdural hematoma. Which is the earliest sign of an increase in intracranial pressure? O 1. A change in level of consciousness. O 2. A widening pulse pressure. O 3. Bradycardia. O 4. Decorticate position.
1) CORRECT - Change in the level of consciousness is the earliest sign of an increase in intracranial pressure. The cranium is a closed cavity and an increase in pressure causes shifting of brain. Causes of increased intracranial pressure include bleeding, tumors, and edema. Indications include change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia (double vision). Treatment includes osmotic diuretics, furosemide, steroids, antihypertensives, anticonvulsants, hyperventilation, and surgery for decompression or shunt. Nursing care includes maintaining airway by suctioning, elevating head of bed 30 degrees, keeping head in the midline position, and administering fluids.
A young adult client diagnosed with hemophilia develops painful swelling of the knee after bumping the leg. In caring for the client, which initial action is most appropriate for the nurse to take? O 1. Apply ice to the knee and elevate the leg. O 2. Type and cross-match the client for 2 units of packed cells. O 3. Explain activity limitations to the client. O 4. Administer analgesics for pain.
1) CORRECT - Hemophilia is a sex-linked recessive trait transmitted to males by female carriers. Clients have a deficiency of factor VIll and experience abnormal bleeding in response to trauma. Painful swelling of the knee indicates acute bleeding into the joint. It is most important to instruct the client to institute supportive measures when trauma occurs, including rest, ice, compression, and elevation (RICE). Applying ice to the knee and elevating the leg is the most appropriate action to take initially because it will help to stop the bleeding, decrease the swelling, and help alleviate the pain.
The nurse provides care for a client diagnosed with severe traumatic brain injury. The client has been placed on a fluid restriction. The client has an intraventricular monitor in place and the intracranial pressure (ICP) reading is 25 mm Hg. What is the rationale for the fluid restriction? O 1. To decrease cerebral edema. O 2. To decrease peripheral edema. O 3. To decrease the need for suctioning. O 4. To decrease the risk of respiratory complications.
1) CORRECT - Strict fluid restrictions are maintained to reduce cerebral edema in a client with increased intracranial pressure. For some clients, administration of fluids is necessary to ensure adequate cerebral perfusion, but fluid volumes must be managed very carefully. The cranium is a closed cavity. The normal intracranial pressure (ICP) for a healthy adult is between 5 and 15 mm Hg. Readings above 20 mm Hg require interventions to lower the ICP so that cerebral perfusion pressures are adequate. Interventions to lower IP include medications such as osmotic diuretics, sedatives and anti-hypertensive agents. The client mav require paralvzation and mechanical ventilation and hyperventilation, or surgery for decompression or shunt placement.
The nurse provides care for a client diagnosed with severe traumatic brain injury. The client has been placed on a fluid restriction. The client has an intraventricular monitor in place and the intracranial pressure (ICP) reading is 25 mm Hg. What is the rationale for the fluid restriction? O 1. To decrease cerebral edema. O 2. To decrease peripheral edema. O 3. To decrease the need for suctioning. O 4. To decrease the risk of respiratory complications.
1) CORRECT - Strict fluid restrictions are maintained to reduce cerebral edema in a client with increased intracranial pressure. For some clients, administration of fluids is necessary to ensure adequate cerebral perfusion, but fluid volumes must be managed very carefully. The cranium is a closed cavity. The normal intracranial pressure (ICP) for a healthy adult is between 5 and 15 mm Hg. Readings above 20 mm Hg require interventions to lower the ICP so that cerebral perfusion pressures are adequate. Interventions to lower IP include medications such as osmotic diuretics, sedatives and anti-hypertensive agents. The client may require paralyzation and mechanical ventilation and hyperventilation, or surgery for decompression or shunt placement.
The nurse performs an assessment for a client reporting severe headaches and new onset seizure activity. At the beginning of the shift, the client is talking with family and vital signs are within normal limits. Six hours later, the nurse finds the client difficult to rouse and unable to speak coherently. The systolic blood pressure is elevated, pulse pressure is widening, and the client has bradycardia. Which is the correct interpretation of these findings? O 1. Increasing intracranial pressure. O 2. Recent tonic clonic seizure activity. O 3. Phenytoin toxicity. O 4. Severe hypertension.
1) CORRECT - When intracranial pressure (ICP) rises, cardiac and vascular reflexes are activated to increase cerebral perfusion pressure. The result is a rise in systolic blood pressure, a fall in diastolic pressure, and a decrease in heart rate. This phenomenon is called "Cushing Triad" and indicates increasing intracranial pressure. Other indications of increased IP include change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia (double vision). The nurse should notify the health care provider immediately.
The nurse performs an assessment for a client reporting severe headaches and new onset seizure activity. At the beginning of the shift, the client is talking with family and vital signs are within normal limits. Six hours later, the nurse finds the client difficult to rouse and unable to speak coherently. The systolic blood pressure is elevated, pulse pressure is widening, and the client has bradycardia. Which is the correct interpretation of these findings? O 1. Increasing intracranial pressure. O 2. Recent tonic clonic seizure activity. O 3. Phenytoin toxicity. O 4. Severe hypertension.
1) CORRECT - When intracranial pressure (ICP) rises, cardiac and vascular retlexes are activated to increase cerebral perfusion pressure. The result is a rise in systolic blood pressure, a fall in diastolic pressure, and a decrease in heart rate. This phenomenon is called "Cushing Triad" and indicates increasing intracranial pressure. Other indications of increased ICP include change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia (double vision). The nurse should notify the health care provider immediately.
A child client diagnosed with hemophilia is seen by the school nurse after falling from a swing and bumping the knee. Which is the first action for the nurse to take? O 1. Administer ibuprofen for the pain. O 2. Apply a cold pack to the knee. O 3. Allow the child to sit in a chair for 30 minutes. O 4. Call an ambulance.
2) CORRECT - A cold pack may help control bleeding into the joint. After a bump on the knee, it would be appropriate to initiate RICE (rest, ice, compression, and elevation). It is appropriate to instruct the client and the client's family: active range of motion after bleeding episodes. To decrease the risk of injury, the client should avoid contact sports, and engage in activities such as swimming and golf. It is best practice to assist the child and family with coping with a chronic disease and altered lifestyle.
The home health nurse visits a child client diagnosed with Hemophilia A. The client's parent asks, "What causes this problem?" The nurse explains that a deficiency of which factor causes Hemophilia A? O 1. VIl. O 2. VIll. O 3. IX. O 4. XI.
2) CORRECT - A deficiency of this factor decreases the blood's ability to clot. Approximately 9 out of 10 people with hemophilia have type A disease. This is also referred to as classic hemophilia or factor VIlI deficiency.
The nurse provides care for a client diagnosed with a closed head injury and increased intracranial pressure. Which action by the nurse is best? O 1. Position client with head of bed flat and client's head in a neutral position. O 2. Instruct client to exhale when turning or moving in bed. O 3. Encourage client to cough and deep breathe every two hours. O 4. Suction client frequently and hyperoxygenate prior to suctioning.
2) CORRECT - The nurse should instruct the client to avoid any movements or positions which increase intracranial pressure. When the client performs a Valsalva maneuver, intracranial pressure is elevated. The client should exhale when moving or turning, avoid straining with stool, or bearing down. The nurse should administer stool softeners.
While providing care for a client diagnosed with an intracranial bleed, the nurse notes the pupils are unequal at 2 mm and 5 mm, the larger pupil is non-reactive to light, and the client only responds to pain. Which explanation does the nurse determine based on this assessment? O 1. The client is blind in one eye. O 2. The client has symptoms of increased intracranial pressure. O 3. These are expected effects from narcotics the client received. O 4. These findings are abnormal but not significant.
2) CORRECT - Cranial nerve III (CN III) is responsible for pupillary constriction and accommodation to light. When a pupil becomes dilated and fixed (non-reactive) it indicates increased pressure on CN III on the ipsilateral (same) side. This is significant of increased intracranial pressure and possible tentorial herniation. Interventions must be taken immediately to decrease intracranial pressure or reduce an expanding lesion, if possible.
While providing care for a client diagnosed with an intracranial bleed, the nurse notes the pupils are unequal at 2 mm and 5 mm, the larger pupil is non-reactive to light, and the client only responds to pain. Which explanation does the nurse determine based on this assessment? O 1. The client is blind in one eye. O 2. The client has symptoms of increased intracranial pressure. O 3. These are expected effects from narcotics the client received. O 4. These findings are abnormal but not significant.
2) CORRECT - Cranial nerve III (CN III) is responsible for pupillary constriction and accommodation to light. When a pupil becomes dilated and fixed (non-reactive) it indicates increased pressure on CN Ill on the ipsilateral (same) side. This is significant of increased intracranial pressure and possible tentorial herniation. Interventions must be taken immediately to decrease intracranial pressure or reduce an expanding lesion, if possible.
The nurse provides care for an infant client diagnosed with a cyanotic congenital heart defect. The nurse understands that chronic hypoxia from this disorder can result in which finding? O 1. Intellectual disability. O 2. Polycythemia. O 3. Respiratory infections. O 4. Fluid retention.
2) CORRECT - In chronic hypoxia, the body tries to compensate by producing more red blood cells (polycythemia) to carry the limited amount of oxygen available to the tissues
Which should the nurse include in the plan of care for a client diagnosed with increased intracranial pressure (ICP)? O 1. Frequently suction the airway. O 2. Teach the client to avoid the Valsalva maneuver. O 3. Position the client supine in a dark room. O 4. Withhold sedatives when the ICP is greater than 20 mm Hg.
2) CORRECT - Nursing actions should focus on reducing or eliminating a further increase in intracranial pressure. Valsalva maneuver is bearing down or forcibly expiring against a closed glottis. This action raises intrathoracic pressure, which reduces cranial venous outflow. Bearing down with defecation, holding the breath while turning, pulling or lifting, sneezing, and gagging will increase intracranial pressure. The nurse should administer stool softeners, instruct the client to breath out while turning or moving in bed, and avoid activities which cause the client to gag and cough,
Which should the nurse include in the plan of care for a client diagnosed with increased intracranial pressure (ICP)? O 1. Frequently suction the airway. O 2. Teach the client to avoid the Valsalva maneuver. O 3. Position the client supine in a dark room. O 4. Withhold sedatives when the ICP is greater than 20 mm Hg.
2) CORRECT - Nursing actions should focus on reducing or eliminating a further increase in intracranial pressure. Valsalva maneuver is bearing down or forcibly expiring against a closed glottis. This action raises intrathoracic pressure, which reduces cranial venous outflow. Bearing down with defecation, holding the breath while turning, pulling or lifting, sneezing, and gagging will increase intracranial pressure. The nurse should administer stool softeners, instruct the client to breath out while turning or moving in bed, and avoid activities which cause the client to gag and cough.
An infant client is diagnosed with a cyanotic congenital heart defect (CCHD). The nurse knows a cyanotic congenital heart defect is associated with which symptom as reported by the parent? O 1. Clubbing of the fingers and swelling of the feet. O 2. Poor feeding with no or very poor weight gain. O 3. Increased crying with increased physical activity. O 4. Warm, pink, dry skin.
2) CORRECT - Reports of poor feeding, difficulty feeding, and poor weight gain or no weight gain are symptoms that occur in infants with congenital heart defects usually seen on the well baby check following birth. There are respiratory related symptoms such as cyanosis, tachypnea, labored breathing, pulmonary edema, and sternal retractions. Circulatory related symptoms are tachycardia, heart murmur, weak femoral pulses, or shock. The infant can also demonstrate lethargy, hepatomegaly, and failure to thrive.
The nurse provides care for a client diagnosed with increased intracranial pressure (ICP) as the result of a closed head injury. The client is unconscious with an intracranial pressure monitoring device in place. Which is the most appropriate position for the nurse to place this client after performing nursing care activities? O 1. High-Fowler's. O 2. Semi-Fowler's. O 3. Right lateral recumbent. O 4. Supine.
2) CORRECT - Semi-Fowler's position increases venous drainage, thus decreasing intracranial pressure. The client with an intracranial pressure monitor in place is typically placed on the back with the head raised 30 degrees and the monitor leveled to the client's lateral ventricle. Causes of increased intracranial pressure following a closed head injury include bleeding and cerebral edema. Uncontrolled increases in intracranial pressure can result in herniation of the brain and death.
The nurse provides care for a client diagnosed with a closed head injury and increased intracranial pressure. Which action by the nurse is best? O 1. Position client with head of bed flat and client's head in a neutral position. O 2. Instruct client to exhale when turning or moving in bed. O 3. Encourage client to cough and deep breathe every two hours. O 4. Suction client frequently and hyperoxygenate prior to suctioning.
2) CORRECT - The nurse should instruct the client to avoid any movements or positions which increase intracranial pressure. When the client performs a Valsalva maneuver, intracranial pressure is elevated. The client should exhale when moving or turning, avoid straining with stool, or bearing down. The nurse should administer stool softeners. 3) The nurse should discourage coughing because it will cause increased intracranial pressure. The nurse will encourage the client to deep breathe and turn side to side.
The nurse provides care for a school-age client with a traumatic brain injury. Which symptoms best indicate increased intracranial pressure? O 1. Headache, crying, sensitivity to loud noises and bright lights. O 2. Widening pulse pressure, slowed respirations, bradycardia. O 3. Hypotension, cyanosis, tachycardia. O 4. Increased temperature, increase in respirations, shaking.
2) CORRECT - These three symptoms are classic characteristics of increased intracranial Flodesk https://flodesk.com.ng triad is a clinical triad variably defined as having irregular, decreased respirations caused by impaired brainstem function; bradycardia; and systolic hypertension with a widening pulse pressure. Causes of increased intracranial pressure include bleeding, tumors, and edema. Measures to decrease increased intracranial pressure include hyperventilation, osmotic diuretics, corticosteroids, metabolically induced coma, and surgery. Without intervention, increasing intracranial pressure can lead to brain herniation and death.
The nurse provides care for a school-age client with a traumatic brain injury. Which symptoms best indicate increased intracranial pressure? O 1. Headache, crying, sensitivity to loud noises and bright lights. O 2. Widening pulse pressure, slowed respirations, bradycardia. O 3. Hypotension, cyanosis, tachycardia. O 4. Increased temperature, increase in respirations, shaking.
2) CORRECT - These three symptoms are classic characteristics of increased intracranial pressure. Cushing triad is a clinical triad variably defined as having irregular, decreased respirations caused by impaired brainstem function; bradycardia; and systolic hypertension with a widening pulse pressure. Causes of increased intracranial pressure include bleeding, tumors, and edema. Measures to decrease increased intracranial pressure include hyperventilation, osmotic diuretics, corticosteroids, metabolically induced coma, and surgery. Without intervention, increasing intracranial pressure can lead to brain herniation and death.
Surgical repair of a congenital heart defect is performed on the 5-month-old infant. Which measure is most important for the nurse to include in the postoperative care plan? O 1. Administer pain medications to the infant to prevent crying. O 2. Elevate the infant's head to reduce respiratory effort. O 3. Administer laxatives to the infant to prevent straining. O 4. Milk the chest tubes to maintain tube patency.
2) CORRECT - elevating the head of the bed assists with respiratory effort, and is an essential component of postoperative care
The nurse cares for the infant immediatelv after insertion of a shunt due to hvdrocephalus. Which observation does the nurse report to the health care provider immediately The nurse cares for the infant immediately after insertion of a shunt due to hydrocephalus. Which observation does the nurse report to the health care provider immediately? O 1. The infant is lying flat in bed. O 2. The infant's pupils are dilated. O 3. The suture line is pink. O 4. Bowel sounds are heard in all quadrants.
2) CORRECT - indicates increased intracranial pressure
The nurse cares for the infant immediately after insertion of a shunt due to hydrocephalus. Which observation does the nurse report to the health care provider immediately? O 1. The infant is lying flat in bed. O 2. The infant's pupils are dilated. O 3. The suture line is pink. O 4. Bowel sounds are heard in all quadrants.
2) CORRECT - indicates increased intracranial pressure
The nurse provides care for a client diagnosed with increased intracranial pressure (IP) as the result of a closed head injury. The client is unconscious with an intracranial pressure monitoring device in place. Which is the most appropriate position for the nurse to place this client after performing nursing care activities? O 1. High-Fowler's. O 2. Semi-Fowler's. O 3. Right lateral recumbent. O 4. Supine.
3) CORRECT - As the pressure within the rigid cranium increases, perfusion of the brain diminishes, resulting in deepening stupor; poorly reactive, dilated pupils; coma; and eventual death. Causes of increased intracranial pressure (ICP) include bleeding, tumors, and edema. Indications of increased ICP include a change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diolopia
A client diagnosed with increased intracranial pressure is drowsy, but will follow commands, and pupils are equal and briskly reactive. When the nurse performs an assessment two hours later, the client is more difficult to rouse and pupils are dilated and sluggishly reactive. How does the nurse interpret this data? O 1. The client needs to have uninterrupted rest. O 2. The client is experiencing improved cerebral function. O 3. The client's condition is deteriorating. O 4. The client has experienced a morphine sulfate overdose.
3) CORRECT - As the pressure within the rigid cranium increases, perfusion of the brain diminishes, resulting in deepening stupor; poorly reactive, dilated pupils; coma; and eventual death. Causes of increased intracranial pressure (ICP) include bleeding, tumors, and edema. Indications of increased IP include a change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia.
A client diagnosed with increased intracranial pressure is drowsy, but will follow commands, and pupils are equal and briskly reactive. When the nurse performs an assessment two hours later, the client is more difficult to rouse and pupils are dilated and sluggishly reactive. How does the nurse interpret this data? O 1. The client needs to have uninterrupted rest. O 2. The client is experiencing improved cerebral function. O 3. The client's condition is deteriorating. O 4. The client has experienced a morphine sulfate overdose.
3) CORRECT - As the pressure within the rigid cranium increases, perfusion of the brain diminishes, resulting in deepening stupor; poorly reactive, dilated pupils; coma; and eventual death. Causes of increased intracranial pressure (IP) include bleeding, tumors, and edema. Indications of increased ICP include a change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia.
The nurse assesses a client diagnosed with cerebral contusion and increased intracranial pressure. Which is the correct initial nursing action? O 1. Placing a footboard to decrease foot drop. O 2. Encouraging head movement to the right. O 3. Elevating the head of the bed 15 to 30 degrees. O 4. Suctioning every 2 hours to maintain the airway.
3) CORRECT - For a client with increased intracranial pressure, the head of the bed should be elevated 15 to 30 degrees and the head placed at midline to promote venous outflow. Elevating the head above 30 degrees can result in a decreased cerebral perfusion pressure.
The nurse assesses a client diagnosed with cerebral contusion and increased intracranial pressure. Which is the correct initial nursing action? O 1. Placing a footboard to decrease foot drop. O 2. Encouraging head movement to the right. O 3. Elevating the head of the bed 15 to 30 degrees. O 4. Suctioning every 2 hours to maintain the airway.
3) CORRECT - For a client with increased intracranial pressure, the head of the bed should be elevated 15 to 30 degrees and the head placed at midline to promote venous outflow. Elevating the head above 30 degrees can result in a decreased cerebral perfusion pressure.
The nurse visits the family with three small children who live in a three bedroom home built in 1952. The nurse counsels the family how to avoid lead poisoning. The nurse determines the teaching is effective if the parent makes which statement? O 1. "I plan to scrape paint off the walls after the children go to bed tonight." O 2. "My children eat meals whenever they are hungry." O 3. "I wet mop all of my floors and wash all of the window sills weekly." O 4. "I'm going to leave that patch of dirt uncovered so the children will have somewhere to dig."
3) CORRECT - Homes with lead paint should be cleaned weekly by wet cleaning all hard surfaces to remove dust that may contain lead; do not dry sweep.
The nurse visits the family with three small children who live in a three bedroom home built in 1952. The nurse counsels the family how to avoid lead poisoning. The nurse determines the teaching is effective if the parent makes which statement? O 1. "I plan to scrape paint off the walls after the children go to bed tonight." O 2. "My children eat meals whenever they are hungry." O 3. "I wet mop all of my floors and wash all of the window sills weekly." O 4. "I'm going to leave that patch of dirt uncovered so the children will have somewhere to dig."
3) CORRECT - Homes with lead paint should be cleaned weekly by wet cleaning all hard surfaces to remove dust that may contain lead; do not dry sweep.
The nurse provides care for a client diagnosed with increased intracranial pressure. Which is the most important short-term goal? O 1. Encourage coughing and deep breathing. O 2. Maintain client in supine position with limited movement. O 3. Control agitation and restlessness. O 4. Avoid bright lights.
3) CORRECT - It is most important for the nurse to avoid or prevent any factors which contribute to a further increase in intracranial pressure (ICP). Agitation increases arterial blood pressure. The client may hold the breath or push against objects when agitated and restless, which will increase intrathoracic pressure and increase intracranial pressure. The client should avoid other activities that increase intrathoracic pressure, such as Valsalva maneuver, coughing, shivering, and sneezing. Indications of elevated ICP include a change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia (double vision).
The nurse provides care for a client diagnosed with increased intracranial pressure. Which is the most important short-term goal? O 1. Encourage coughing and deep breathing. O 2. Maintain client in supine position with limited movement. O 3. Control agitation and restlessness. O 4. Avoid bright lights.
3) CORRECT - It is most important for the nurse to avoid or prevent any factors which contribute to a further increase in intracranial pressure (ICP). Agitation increases arterial blood pressure. The client may hold the breath or push against objects when agitated and restless, which will increase intrathoracic pressure and increase intracranial pressure. The client should avoid other activities that increase intrathoracic pressure, such as Valsalva maneuver, coughing, shivering, and sneezing. Indications of elevated ICP include a change in LOC, restlessness, confusion, pupil changes, motor changes, cardiac rate changes, headache, nausea and vomiting, and diplopia (double vision).
The 1-week-old chient is diagnosed with hemophilia A. Neither parent has the disease. Which statement correctly describes the hemophilia trait? O 1. "It is an X-linked recessive trait found primarily in females." O 2. "It is an X-linked dominant trait found primarily in females." O 3. "It is an X-linked recessive trait found primarily in males." O 4. "It is an X-linked dominant trait found primarily in males."
3) CORRECT - This trait very rarely shows itself in females, since the second sex chromosome is also an X. Females would need to have the trait linked to both chromosomes in order to show the disease. Since the second sex chromosome in males is a Y, males will show the disease. A female who has the trait linked to one X chromosome and not the other is considered a carrier.
The parents of a newly circumcised infant client are informed that their child has hemophilia A. One parent is crying and expresses concern that the child will "bleed to death". The other parent says, "Just give me the facts. We will deal with it." It is most important for the nurse to give the parents which information initially? O 1. The necessity for avoiding contact sports and other potentially injurious activities. O 2. The importance of a diet high in protein, carbohydrates, calories. O 3. The improvements in psychological counseling related to coping with life-long limitations. O 4. The availability of replacement therapy of clotting factors.
4) CORRECT - Addressing the availability of clotting factors is the most important information for the nurse to give initially because it is accurate information and will most immediately address the fears of the parents. Hemophilia results from either a deficiency of factor VIll or factor IX clotting factors in the blood. Antihemophilic factor (AHF) replacement therapy is the primary therapy for this disorder. Circumcision, initial ambulation, or initial tooth eruption are times when severe hemophilia is often first detected.
The nurse reviews the medical record for a client diagnosed with hemophilia. It is most important for the nurse to question which entry? O 1. Apply a splint to the left knee. O 2. Acetaminophen with codeine 1 tablet PO q 4 hr prn for pain. O 3. Vital signs q 4 hr. O 4. Meperidine 75 mg IM q 4 hr prn for severe pain.
4) CORRECT - Intramuscular injections should be avoided for the client diagnosed with hemophilia due to the high risk of bleeding into the tissue. The nurse should contact the health care provider to question this prescribed medication.
An adolescent client is evaluated for scoliosis. The client asks the nurse, "What is scoliosis?" Which statement by the nurse best describes scoliosis? O 1. "It is an inward curvature of the lower spine." O 2. "It is an exaggerated convexity in the thoracic region of the spine." O 3. "It is the herniation of an intervertebral disc." O 4. "It is a lateral curvature of a portion of the spine."
4) CORRECT - Scoliosis is a lateral curvature of a portion of the spine. It is diagnosed by having the client bend at the waist to assess the spine. If the client wears a brace, good skin care under pressure areas is necessary and the brace is worn 23 hours per day.
A brace is ordered for the adolescent to correct a scoliosis deformity. Which parental statement indicates teaching is successful? O 1. "A bed board may replace the brace at night." O 2. "My child's diet should be low in calories." O 3. "Daily tub baths are preferred to showers." O 4. "The brace should be worn 23 hours a day."
4) CORRECT - should be worn 23 hours per day; nurse should assess home environment for safety hazards; teach child how to prevent falls by using handrails and avoiding slippery surtaces
