Before the patient diagnosed with a concussion is released from the Emergency Department, the nurse teaches the family or friends who will be tending to the patient to contact the physician or return to the ED if the patient a) vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

Before the patient diagnosed with a concussion is released from
the Emergency Department, the nurse teaches the family or friends
who will be tending to the patient to contact the physician or return
to the ED if the patient
a) vomits.
Vomiting is a sign of increasing intracranial pressure and should be
reported immediately.
b) complains of headache.
In general, the finding of headache in the patient with a concussion is
an expected abnormal observation. However, severe headache should
be reported or treated immediately.
c) complains of generalized weakness.
Weakness of one side of the body should be reported or treated
immediately.
d) sleeps for short periods of time.
Difficulty in waking the patient should be reported or treated
immediately.
by

1 Answer

Answer :

a) vomits.
Vomiting is a sign of increasing intracranial pressure and should be
reported immediately.
by

Related questions

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Description : The Emergency Department nurse teaches patients with sports injuries to remember the acronym RICE, which stands for which of the following combinations of treatment? a) Rest, ice, compression ... contraindicated when injury is suspected, and examination, while indicated, does not provide treatment.

Last Answer : a) Rest, ice, compression, elevation RICE is used for the treatment of contusions, sprains, and strains.

Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of left-heart failure. b) Increased appetite Loss of appetite should be reported immediately. c) Weight loss Weight gain should be reported immediately. d) Ability to sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Description : The patient with cardiac failure is taught to report which of the following symptoms to the physician or clinic immediately? a) Persistent cough Persistent cough may indicate an onset of ... sleep through the night Frequent urination, causing interruption of sleep, should be reported immediately.

Last Answer : a) Persistent cough Persistent cough may indicate an onset of left-heart failure.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach. b) Minimize intake of caffeine, ****, milk, and foods containing peppermint and spearmint. The patient should be instructed to avoid the listed foods and food components. c) Elevate the foot of the bed on 6- to 8-inch blocks The patient should be instructed to elevate the head of the bed on 6- to 8-inch blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Description : The nurse teaches the patient with gastroesophageal reflux disease (GERD) which of the following measures to manage his disease? a) Avoid eating or drinking 2 hours before bedtime. The patient should not ... blocks. d) Eat a low carbohydrate diet The patient is instructed to eat a low-fat diet

Last Answer : a) Avoid eating or drinking 2 hours before bedtime. The patient should not recline with a full stomach.

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

Description : Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a) Widened pulse pressure Additional signs of increasing ICP ... regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.

Last Answer : a) Widened pulse pressure Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature.

If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision of diagnostic support and eventual release of vaccine if a case is confirmed. Until instructed otherwise by the CDC, healthcare providers should carefully establish isolation with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Description : If a case of smallpox is suspected, the nurse should a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office ... very different from that of chickenpox. With chickenpox, lesions appear at different developmental stages.

Last Answer : a) Call the CDC Emergency Preparedness Office. Anyone suspecting a case of smallpox should call the CDC Emergency Preparedness Office at 770-488-7100. The CDC will respond by immmediate provision ... with negative pressure, and maintain thorough lists of all those who have contact with the patient.

Later signs of increased intracranial pressure (ICP) later include which of the following? a) Projectile vomiting Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

Description : Later signs of increased intracranial pressure (ICP) later include which of the following? a) Projectile vomiting Projectile vomiting may occur with increased pressure on the reflex center in the ... , the pulse pressure (the difference between the systolic and the diastolic pressure) widens.

Last Answer : a) Projectile vomiting Projectile vomiting may occur with increased pressure on the reflex center in the medulla.

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

Description : The nurse teaches the parent of the child with chickenpox that the child is no longer contagious to others when a) the vesicles and pustules have crusted. When the lesions have crusted, the ... , and pustules appear. The child remains contagious when the rash is changing into vesicles and pustules.

Last Answer : a) the vesicles and pustules have crusted. When the lesions have crusted, the patient is no longer contagious to others.

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

Description : The nurse teaches the patient who demonstrates herpes zoster (shingles) that a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a ... is arrested if oral antiviral agents are administered within 24 hours of the initial eruption.

Last Answer : a) the infection results from reactivation of the chickenpox virus. It is assumed that herpes zoster represents a reactivation of latent varicella (chickenpox) virus and reflects lowered immunity.

The nurse teaches the patient with allergies about anaphylaxis including which of the following statements? a) The most common cause of anaphylaxis is penicillin. The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the U.S., is penicillin.

Description : The nurse teaches the patient with allergies about anaphylaxis including which of the following statements? a) The most common cause of anaphylaxis is penicillin. The most common ... 30 minutes of exposure involving cardiovascular, respiratory, gastrointestinal, and integumentary organ systems.

Last Answer : a) The most common cause of anaphylaxis is penicillin. The most common cause of anaphylaxis, accounting for about 75% of fatal anaphylactic reactions in the U.S., is penicillin.

The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Description : The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed ... retention before their menstrual period, BSE is best performed when the time for menses is taken into account.

Last Answer : a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

The nurse teaches the patient about glargine (Lantus), a “peakless” basal insulin including which of the following statements? a) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

Description : The nurse teaches the patient about glargine (Lantus), a peakless basal insulin including which of the following statements? a) Do not mix the drug with other insulins Because glargine is in a ... action Glargine is a peakless basal insulin that is absorbed very slowly over a 24-hour period.

Last Answer : a) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering ... to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Description : The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood ... be able to resume previous methods for control of diabetes when the stress is resolved.

Last Answer : a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi-mushy. With a descending colostomy, the feces are semi-mushy. c) mushy. With a transverse colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.

The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities. b) slowed heart rate. Nicotine has stimulant effects. c) depression of the cough reflex. Nicotine does not suppress cough. Smoking irritates the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Description : The nurse teaches the patient with peripheral vascular disease to refrain from smoking because nicotine causes a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the ... the bronchial tree, causing coughing. d) diuresis. Nicotine does not cause diuresis.

Last Answer : a) vasospasm. Nicotine causes vasospasm and can thereby dramatically reduce circulation to the extremities.

When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

Description : When the nurse prepares to give a bolus tube feeding to the patient and determines that the residual gastric content is 150 cc, her best action is to a) reassess the residual gastric content in ... residual exceeds 100 cc, the tube feeding should be withheld at that time, but not indefinitely.

Last Answer : a) reassess the residual gastric content in 1 hour. If the gastric residual exceeds 100 cc 2 hours in a row, the physician should be notified.

Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts. b) Requires a physician’s order. Teaching, as a function of nursing, is included in all state nurse practice acts. c) Must be approved by the physician. Health education is a primary responsibility of the nursing profession. d) Must focus on wellness issues. Health education by the nurse focuses on promoting, maintaining, and restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Description : Health education of the patient by the nurse a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state ... restoring health; preventing illness; and assisting people to adapt to the residual effects of illness.

Last Answer : a) Is an independent function of nursing practice. Health education is an independent function of nursing practice and is included in all state nurse practice acts.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

Description : An osmotic diuretic, such as Mannitol, is given to the patient with increased intracranial pressure (IICP) in order to a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics ... Medications such as barbiturates are given to the patient with IICP to reduce cellular metabolic demands.

Last Answer : a) dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Description : A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken ... headaches. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Last Answer : a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Description : The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding ... encouraged to void every 2-3 hours during the day and completely empty the bladder.

Last Answer : a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

Description : When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a ... Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Last Answer : a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

Description : The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly ... following a basal skull fracture. The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.

Last Answer : a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) 140, 90 According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140–159 or a diastolic pressure of 90–99.

Description : Officially, hypertension is diagnosed when the patient demonstrates a systolic blood pressure greater than ______ mm Hg and a diastolic blood pressure greater than _____ mm Hg over a sustained period. a) ... , 70 Pressure of 120 systolic and 70 diastolic falls within the normal range for an adult.

Last Answer : a) 140, 90 According to the categories of blood pressure levels established by the JNC VI, stage 1 hypertension is demonstrated by a systolic pressure of 140–159 or a diastolic pressure of 90–99.

The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

Description : The nurse anticipates that the physician will perform joint aspiration and wrapping with compression elastic dressing for which of the following musculoskeletal problems? a) Joint effusion The described ... of tissue due to insufficient blood supply and may be associated with steroid use.

Last Answer : a) Joint effusion The described treatments are used with joint effusions and hemarthrosis.

30. A T-tube was inserted and the physician ordered, “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order?

Description : 30. A T-tube was inserted and the physician ordered, “Monitor the amount, color, consistency and odor of drainage.” Which of the following procedures can the nurse perform without the doctor’s order?

Last Answer : D. Emptying the drainage

To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 – 2 cm and inflammation. The nurse would prepare the client for which specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Description : To confirm the diagnosis of cholecystitis, the attending physician ordered a procedure that can detect gallstones as small as 1 - 2 cm and inflammation. The nurse would prepare ... specific diagnostic procedure? A. Cholangiography B. Ultrasonography C. Gall bladder series D. Oral cholecystogram

Last Answer : B. Ultrasonography

The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Description : The client complained of abdominal pain, nausea and vomiting with abdominal distention. The nurse anticipates which of the following priority management after referring to the surgeon? A. Gastric decompression B. Possible surgery C. Endoscopy D. Rectal tube insertion

Last Answer : A. Gastric decompression

The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

Description : The first dressing change for an autografted area is performed a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent ... is noted. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.

Last Answer : a) as soon as foul odor or purulent drainage is noted, or 3-5 days after surgery. A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately.

When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma. b) normal. A class 1 Pap smear is interpreted as normal. c) probably normal. A class 2 Pap smear is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Description : When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is a) malignant. A class 5 Pap smear, according to the Bethesda Classification, ... is interpreted as probably normal. d) suspicious. A class 3 Pap smear is interpreted as suspicious.

Last Answer : a) malignant. A class 5 Pap smear, according to the Bethesda Classification, indicates squamous cell carcinoma.

The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log every injection of Demerol B. Make fraction dosage like 0.5 ml as 1 ml C. Demerol inventory must be checked every endorsement by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Description : The charge nurse reported to the chief nurse that the Demerol 50 cc vial inventory has been incorrect for the last 24 hours. The most appropriate action of the narcotic nurse is: A. Log ... by the narcotic nurse D. Review endorsement of clients who received Demerol within the last 24 hours

Last Answer : D. Review endorsement of clients who received Demerol within the last 24 hours

Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at a) controlling seizures and increased intracranical pressure. There is no specific medication for arboviral encephalitis. Medical management is aimed at controlling seizures and increased intracranial pressure.

Description : Medical management of arthropod-borne virus (arboviral) encephalitis is aimed at a) controlling seizures and increased intracranical pressure. There is no specific medication for arboviral ... muscular atrophy. Medical management is aimed at controlling seizures and increased intracranial pressure.

Last Answer : a) controlling seizures and increased intracranical pressure. There is no specific medication for arboviral encephalitis. Medical management is aimed at controlling seizures and increased intracranial pressure.

Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.

Description : Which of the following positions are employed to help reduce intracranial pressure (ICP)? a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous ... an increase in intra-abdominal pressure and intrathoracic pressure, which can produce a rise in ICP.

Last Answer : a) Avoiding flexion of the neck with use of a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion that will increase ICP.

79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, “How old is the client?” Holding the fallopian tube, the surgeon asks for a hemostat. The scrub nurse sensing that the surgeon is about to ligate the tube said, “Doctor there is no signed consent for tubal ligation.” The nurse just demonstrated which of the following?

Description : 79. A scrub nurse is assisting an emergency Cesarian section on a 39-year-old laundry woman. Before closing the peritoneum, the surgeon asks, How old is the client? Holding the fallopian ... there is no signed consent for tubal ligation. The nurse just demonstrated which of the following?

Last Answer : C. Advocacy

Induction of vomiting is indicated for the accidental poisoning patient who has ingested a) aspirin. Overdose of aspirin should be treated with emesis or lavage, followed by ingestion of activated charcoal to absorb the aspirin.

Description : Induction of vomiting is indicated for the accidental poisoning patient who has ingested a) aspirin. Overdose of aspirin should be treated with emesis or lavage, followed by ingestion of ... d) toilet bowl cleaner. Toilet bowl cleaners are corrosive, and induced vomiting is contraindicated.

Last Answer : a) aspirin. Overdose of aspirin should be treated with emesis or lavage, followed by ingestion of activated charcoal to absorb the aspirin.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to Fowler’s B. Reassure the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Description : In the immediate post-operative period, the nurse assesses coarse, high-pitched sound on inspiration by listening over the trachea with a stethoscope. The nurse should immediately A. Position client to ... the client that he is doing fine C. Suction the tracheostomy tube D. Report to the surgeon

Last Answer : Which of the following expected outcomes for the patient is most relevant for the nursing diagnosis “At risk for imbalanced nutrition related to impaired swallowing”? A. Appropriate body weight maintained B. Fear of choking relieved C. Oral intake increased D. Swallowing of soft foods facilitated

Which of the following types of lung cancer is characterized as fast growing and tending to arise peripherally? a) Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally. b) Bronchioalveolar carcinoma Bronchioalveolar cell cancer arises from the terminal bronchus and alveoli and is usually slow-growing. c) Adenocarcinoma Adenocarcinoma presents as peripheral masses or nodules and often metastasizes. d) Squamous cell carcinoma Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.

Description : Which of the following types of lung cancer is characterized as fast growing and tending to arise peripherally? a) Large cell carcinoma Large cell carcinoma is a fast-growing tumor that ... cell carcinoma Squamous cell carcinoma arises from the bronchial epithelium and is more centrally located.

Last Answer : a) Large cell carcinoma Large cell carcinoma is a fast-growing tumor that tends to arise peripherally.

Which type of Mendelian inherited condition results in both genders being affected equally in a vertical pattern? a) Automosomal dominant inheritance An individual who has an autosomal dominant inherited condition carries a gene mutation for that condition on one chromosome of a pair. b) Automosomal recessive inheritance The pattern of inheritance in autosomal recessive inherited conditions is different from that of autosomal dominant inherited conditions in that it is more horizontal than vertical, with relatives of a single generation tending to have the condition. c) X-linked inheritance X-linked conditions may be inherited in families in recessive or dominant patterns.

Description : Which type of Mendelian inherited condition results in both genders being affected equally in a vertical pattern? a) Automosomal dominant inheritance An individual who has an autosomal dominant ... that combine during early embryonic development leading to incomplete closure of the neural tube.

Last Answer : a) Automosomal dominant inheritance An individual who has an autosomal dominant inherited condition carries a gene mutation for that condition on one chromosome of a pair.

Nurse Mercy is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer. The nurse’s appropriate action is A. Bring the linen packs back to the Central Supply section for quality control B. Change the damp linen pack C. Open the linen pack and allow to dry D. Do not use the damp linen

Description : Nurse Mercy is setting up for an emergency caesarian section. The linen packs were damp although these were just taken from the sterilizer. The nurse's appropriate action is A. Bring the linen packs back to the ... linen pack C. Open the linen pack and allow to dry D. Do not use the damp linen

Last Answer : D. Do not use the damp linen