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.

Nursing Test Bank

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Correct Answer is A

Explanation

A. Acute pain deep within the eye following laser trabeculoplasty surgery may indicate a serious complication such as increased intraocular pressure or infection. It is crucial to report this symptom to the surgeon immediately for further evaluation and management.

B. Administering an antiemetic is not directly related to addressing the acute eye pain.

C. Applying bilateral eye shields can help with photosensitivity but does not address the underlying cause of the acute pain.

D. Beginning postoperative prophylactic antibiotics may be necessary but does not address the immediate concern of the acute pain reported by the client.

A. Family history of schizophrenia. B. History of suicide attempts. C. Undiagnosed social anxiety symptoms (SAD). D. Feelings of disorientation.

Correct Answer is B

Explanation

A. Family history of schizophrenia is relevant but not immediately critical.

B. A history of suicide attempts indicates a high risk of self-harm and requires immediate attention in the plan of care.

C. Social anxiety symptoms are important but not as critical as addressing suicide risk.

D. Disorientation needs assessment but is not as urgent as managing suicide risk.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Following laser trabeculoplasty surgery for open-angle glaucoma, the client reports acute pain deep within the eye. Which action should the nurse take?

Correct Answer is A

Explanation

During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

Correct Answer is B

Explanation

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?

A client with purulent drainage from an abdominal surgical incision is admitted with a possible vancomycin-resistant enterococci (VRE) infection. Which nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Twelve hours after experiencing a traumatic closed fracture of the lower left tibia, a client reports pain, tingling, and diminished toe movement in the left foot. Which nursing problem has the highest priority based on this information?

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 are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?

A client newly diagnosed with diabetes mellitus suddenly becomes confused and weak. Which intervention(s) should the nurse implement? Select all that apply.