The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?
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Solution
Answer D is correct. Papilledema is a hallmark symptom of increased intracranial pressure. Answers A, B, and C are not as objective or specific to increased intracranial pressure as papilledema.
The nurse is reading an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
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Solution
Answer A is correct. Plavix is an antiplatelet. Bleeding could indicate a severe effect. Answers B, C, and D are not associated with Plavix.
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
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Solution
Answer B is correct. The client is experiencing autonomic hyperreflexia. This can be caused by a full bowel or bladder or a wrinkled sheet. Answer A is not the appropriate action before the assessment of the bladder. Answers C and D are not appropriate actions. There is no information to suggest a need for oxygen, and Procardia requires a doctor’s order and would not be done prior to assessment.
The nurse is caring for a client with a head injury who has increased ICP. The physician plans to reduce the cerebral edema by constricting the cerebral blood vessels. Which of the following would accomplish this action?
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Solution
Answer A is correct. Hyperventilation is utilized to decrease the PCO2 to 27–30, producing cerebral blood vessel constriction. Answers B, C, and D can decrease cerebral edema, but not by constricting cerebral blood vessels.
A client with suspected leukemia is about to undergo a bone marrow aspiration from the sternum. What position would the nurse assist the client into for this procedure?
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Solution
Answer C is correct. This procedure is usually done by the physician with specimens obtained from the sternum or the iliac crest. The high Fowler’s position would be the best position of the ones listed to obtain a specimen from the client’s sternum. Answers A, B, and D would be inappropriate positions for getting a biopsy from the sites indicated.
The nurse is caring for a client with hyperthyroidism. Which clinical manifestation should be reported to the physician immediately?
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Solution
Answer B is correct. Heart failure can be life threatening and would be a priority for reporting. These clients are hyperactive and restless, making answers C and D incorrect. Urinary retention, as in answer A, is not a clinical manifestation of hyperthyroidism.
The nurse is caring for a client with cancer of the cervix. What clinical data would the nurse expect to find in the client’s history?
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Solution
Answer A is correct. Vaginal bleeding or spotting is a common symptom of cervical cancer. Answers B and C, the nausea and vomiting and foul-smelling discharge, are not specific or common to cervical cancer. Hyperthermia, in answer D, does not relate to the diagnosis.
A client has a subtotal thyroidectomy. The nurse is observed requesting that the client state her name frequently. The primary reason for this assessment is to monitor for which of the following?
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Solution
Answer A is correct. The nurse would monitor the client for hoarseness or a voice change, which could indicate damage to the laryngeal nerve during the surgical procedure. Although the nurse would monitor for edema, bleeding, and tetany, assessment of these problems would not be performed by asking the client to speak.
The nurse who is caring for a client with cancer notes a WBC of 1,000. Which intervention would be most appropriate to include when caring for this client?
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Solution
Answer B is correct. With neutropenia, the client is at risk for infection; therefore, the client must avoid crowds and people who are ill. Answer A would not be appropriate because there is no correlation between hypothermia and a WBC of 1000. Answers C and D would correlate with a risk for bleeding.
A client is admitted with Parkinson’s disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be most important to report?
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Solution
Answer B is correct. Spasmodic eye winking could indicate a toxicity or overdose of the drug and should be reported to the physician. Other signs of toxicity include an involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are side effects but do not indicate toxicity of the drug.