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A nurse is caring for a newborn who was born prematurely at 26 weeks. Which of the following interventions should the nurse take to decrease the newborn's risk of increased intracranial pressure?

Elevate the head of the bed 15° to 20°.

Stimulate the newborn every 2 hr.

Place the newborn in a radiant warmer.

Administer hypertonic solution.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Elevating the head of the bed can help prevent intracranial pressure by promoting venous drainage from the head.

Choice B rationale:

Premature newborns need to rest and conserve energy, so excessive stimulation every 2 hours is not recommended.

Choice C rationale:

Placing the newborn in a radiant warmer helps maintain a stable body temperature, but it does not directly address intracranial pressure.

Choice D rationale:

Administering hypertonic solution is not a standard intervention for decreasing intracranial pressure in a premature newborn.

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Correct Answer is B

Explanation

Choice A rationale:

Appointing the client as a leader may not be appropriate, as individuals with antisocial personality disorder may misuse their position of authority.

Choice B rationale:

Clients with antisocial personality disorder often struggle with interpersonal relationships, may be manipulative, and may engage in behaviors that violate the rights of others. Monitoring the client's interactions with other clients helps ensure a safe and therapeutic environment while preventing harm to others.

Choice C rationale:

Offering warnings before consequences might not be effective with clients who have antisocial personality disorder, as they may disregard rules and consequences.

Choice D rationale:

Assigning a room near the activity area does not necessarily address the need to monitor the client's interactions with others.

A. Blood pressure 78/60 mm Hg B. Weight loss 20% over last 6 months C. Apical pulse rate 50/min D. Body temperature 35.5° C (95.9°F)

Correct Answer is D

Explanation

Choice A rationale:

A blood pressure of 78/60 mm Hg is indicative of hypotension which is a common complication of anorexia nervosa. However. the low body temperature takes precedence

Choice B rationale:

Weight loss of 20% over the last 6 months is concerning but may not be an immediate indicator for acute care admission.

Choice C rationale:

An apical pulse rate of 50/min is bradycardia, which can be a result of anorexia nervosa, but it may not be an immediate indicator for acute care admission unless the client is symptomatic.

Choice D rationale:

A body temperature of 35.5°C (95.9°F) is below a normal range signfyng hypothermia which needs immedate intervention.

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A nurse is caring for a newborn who was born prematurely at 26 weeks. Which of the following interventions should the nurse take to decrease the newborn's risk of increased intracranial pressure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care for a client who has antisocial personality disorder. Which of the following interventions should the nurse include?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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