A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

Cardiogenic shock

Left ventricular failure

Hypotension

Hypovolemia

Answer and Explanation

The Correct Answer is B

Choice A reason: Cardiogenic shock involves reduced cardiac output, typically with low PAWP due to decreased preload from poor heart function. Elevated PAWP reflects left atrial pressure buildup, not characteristic of cardiogenic shock alone, which is distinct from heart failure, requiring specific hemodynamic management.
Choice B reason: Elevated PAWP indicates left ventricular failure, where the heart cannot pump blood effectively, causing pulmonary congestion. This increases left atrial pressure, leading to pulmonary edema, a hallmark of heart failure. Diuretics and inotropes are needed to reduce fluid overload and improve cardiac function.
Choice C reason: Hypotension is a symptom, not a direct complication of elevated PAWP. It may occur in heart failure due to reduced cardiac output, but elevated PAWP specifically signals left heart dysfunction, not hypotension itself, which is a systemic response rather than a primary cardiac issue.
Choice D reason: Hypovolemia reduces blood volume, lowering PAWP due to decreased preload. Elevated PAWP suggests fluid overload or left ventricular dysfunction, not hypovolemia, which presents with low central venous pressure and dehydration signs, requiring fluid resuscitation rather than management of heart failure.

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Correct Answer is B

Explanation

Choice A reason: Attaching restraints to movable side rails is unsafe, as rail movement can cause injury or loosen restraints. They should be secured to the bed frame, a fixed structure, so this guideline is incorrect and dangerous for restraint protocols.
Choice B reason: Documenting the client’s condition every 15 minutes ensures frequent monitoring for safety, circulation, and skin integrity, per CMS and Joint Commission standards. This prevents complications and supports timely restraint removal, making it the correct guideline.
Choice C reason: Requesting PRN restraint prescriptions is inappropriate, as restraints require specific, time-limited orders based on immediate need. PRN orders lack oversight and risk misuse, so this guideline is incorrect and non-compliant with regulations.
Choice D reason: Applying restraints over clothing can cause discomfort or skin irritation, as direct skin contact with padding is preferred for safety. This guideline is incorrect, as proper application minimizes harm, making it inappropriate for protocols.

A. The child usually has an aura before the seizure. B. This type of seizure lasts 30 to 60 seconds. C. This type of seizure requires surgical intervention. D. The child may appear to be daydreaming during the seizure.

Correct Answer is D

Explanation

Choice A reason: Absence seizures lack an aura, unlike focal seizures. They involve brief, sudden lapses in consciousness due to generalized cortical discharges, without premonitory symptoms, making this incorrect for educating parents about the characteristics of absence seizures in children.
Choice B reason: Absence seizures last 5-20 seconds, not 30-60 seconds. These brief staring spells are caused by spike-wave discharges on EEG. Prolonged duration suggests other seizure types, making this inaccurate for teaching parents about absence seizure presentation and duration.
Choice C reason: Absence seizures are managed with anticonvulsants like ethosuximide, not surgery. Surgical intervention is for refractory focal seizures, not generalized absence seizures, which respond to medication. This is incorrect for educating parents about treatment options for absence seizures.
Choice D reason: Absence seizures cause a daydreaming appearance, with staring and brief unresponsiveness due to synchronized cortical discharges. This hallmark symptom, lasting seconds, is critical for parents to recognize, aiding identification and management of absence seizures in school settings.

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A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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