A client has signs of increased intracranial pressure. Which one of the following is an early indicator of increased intracranial pressure?
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Solution
Answer D is correct. The nurse observes sluggishness and lethargy as early indications of increased ICP in a client. A change in vital signs and papillary changes, as in answers A, B, and C, are late signs of increased ICP.
A client at the clinic reports to the nurse, “I have trouble seeing signs at a distance, but no trouble seeing things close up.” The nurse identifies the correct term for this vision problem as:
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Solution
Answer A is correct. Myopia is nearsightedness due to the cornea being too steep or the eye being too long. This causes light to come into focus in front of the retina, resulting in blurred distant vision. Answer B is normal vision. Farsightedness is blurred near and often distant vision, as in answer C. Astigmatism occurs when light rays focus in multiple points, causing blurred vision not related to near or far vision; thus, answer D is incorrect.
The nurse is assessing elderly clients at a nursing home. Which of the following findings would not be considered a normal part of the aging process?
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Solution
Answer D is correct. Rales would indicate lung congestion and the need for follow-up. Answers A, B, and C are normal health-related changes with aging.
A client has an order for Codeine 60 mg IM. An available vial contains Codeine 30 mg/mL. What volume of drug would the nurse administer?
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Solution
Answer D is correct. The dose to administer is 2mL, which is calculated as follows: 60 mg?= 1 mL/30 mg=60/30 = 2.0 mL Answers A, B, and C are incorrect calculations.
The nurse is assessing a client with gastroenteritis for hypovolemia. Which laboratory result would help the nurse in confirming a volume deficit?
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Solution
Answer A is correct. Hematocrit levels can be elevated with hypovolemia caused by fluid loss. Answers B, C, and D are all normal levels. Potassium (normal 3.5–5.3mEq/L) levels would be decreased with hypovolemia; BUN (normal 5–20mg/dL) and specific gravity (1.016–1.022) levels would be elevated with hypovolemia.
A client is admitted with cholethiasis and has obstructive jaundice. Which clinical manifestations does the LPN/LVN expect to observe?
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Solution
Answer C is correct. The obstruction decreases the elimination of bile causing the collection of bilirubin in the blood instead of it being removed by the urinary and Gastrointestinal system. This leads to a lack of normal color of the stool and urine. Answers A, B, and D do not occur with obstructive jaundice so they are incorrect.
Which breakfast selection by a client with osteopenia indicates that the client understands the dietary management of the disease?
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Solution
Answer D is correct. The highest amount of calcium is in this answer. The client also needs to know that calcium in combination with high fiber and caffeine decreases the absorption; therefore, answers A, B, and C are incorrect.
The nurse identifies which of the following as a side effect of the influenza vaccine?
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Solution
Answer A is correct. The client, especially a child, could experience a febrile reaction. This makes hypothermia or a decreased temperature, as in answer B, incorrect. Another side effect is soreness at the injection site. A generalized rash and difficulty breathing are not side effects of the vaccine; therefore, answers C and D are incorrect.
The nurse is caring for a client who is of the Islam religious group. Which food selection would be inappropriate to offer to this client?
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Solution
Answer A is correct. People of the Islam religion are prohibited from eating foods with gelatin. They also must avoid pork, alcohol products and beverages, and animal shortening. Answers B, C, and D would all be appropriate because they can be included in the diet of people of the Islam religion.
The influenza vaccine is contraindicated in clients with allergies to which of the following?
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Solution
Answer A is correct. The vaccine is made from eggs, so clients with allergies to eggs should not receive the vaccine. Shellfish and iodine are associated with the dye used for intravenous pyelograms, so answers B and C are incorrect. An allergy to pork, as in answer D, does not indicate a need to avoid the influenza virus.