Patient Data

Exhibits

Review H and P, nurse's note, flow sheet, and prescriptions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

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Correct Answer is C

Explanation

A. While explaining medications for anxiety is helpful, understanding the client's specific fears is crucial for addressing their concerns effectively.

B. Reviewing the home health care plan is important but should follow addressing the client's immediate concerns and fears about going home.

C. Asking the client about their fears helps to address specific concerns and provides an opportunity to offer targeted support and reassurance.

D. While privacy is important, it is not as critical as understanding and addressing the client's fears directly.

A. Ensure that prescribed medications are kept in a safe place in the room. B. Replace paper trash bags with plastic biohazard bags. C. Remove soft drink cans from the nurse's desk and patient lounge. D. Take the client's cellular telephone and provide a telephone in the room.

Correct Answer is C

Explanation

A. Ensuring medications are kept in a safe place is important but may not directly impact safety in the milieu.

B. Replacing paper trash bags with biohazard bags is unnecessary unless there is a specific reason related to infection control.

C. Removing soft drink cans can prevent them from being used inappropriately (e.g., for self-harm or as weapons), contributing to a safer environment.

D. Taking the client's cellular telephone and providing a room telephone may be necessary for some clients but is not a universal safety measure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing discharge instructions for a client who had an above the knee amputation (AKA) and their spouse. The client expresses fear about going home and requests to stay in the hospital one more day. Which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

Correct Answer is C

Explanation

The nurse is planning the preoperative teaching plan for a 12-year-old child who is scheduled for surgery. To help reduce this child's anxiety, which action is best for the nurse to implement?

Patient Data Exhibits The nurse suspects elder mistreatment. Click to indicate if the listed manifestation of abuse is consistent with physical abuse, abandonment, or neglect. Each row must have only one response option selected.

While preparing a client's routine 0800 medications, the nurse opens the medication packaging and discards in the trash prior to scanning the barcode label. Which action should the nurse implement?

While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

A client with advanced cirrhosis is being treated for hepatic encephalopathy. In reviewing the client's serum laboratory results, which finding requires the most immediate intervention by the nurse?

Patient Data Exhibits Which 2 prescriptions should the nurse complete first?