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 B

Explanation

In end-stage kidney failure, nephron damage is permanent and irreversible. Increasing protein does not restore kidney function.

B. Clients with end-stage kidney disease (ESKD) who are receiving dialysis require increased protein intake. Dialysis removes not only waste products but also amino acids and proteins. Without adequate protein intake, the client is at risk for malnutrition, muscle wasting, poor wound healing, and decreased energy. Therefore, protein intake is increased to replace losses and maintain nutritional status.

C. Protein restriction is appropriate in earlier stages of chronic kidney disease to reduce workload on the kidneys. However, once the client is on dialysis, protein needs increase.

D. Protein intake should be decreased to prevent the buildup of nitrogenous wastes, which the failing kidneys cannot adequately filter. Dialysis can help remove these wastes, but dietary management is still crucial.

A. Monitor oxygen saturation (SpO2) via continuous pulse oximetry. B. Observe neck for jugular vein distention. C. Notify healthcare provider to prepare for pericardiocentesis. D. Assess for paradoxical blood pressure.

Correct Answer is C

Explanation

A. Monitoring oxygen saturation is important but secondary to addressing the immediate cause of the cardiac tamponade.

B. Observing for jugular vein distention is relevant but not the priority compared to directly addressing the tamponade.

C. Notifying the healthcare provider to prepare for pericardiocentesis is the most critical intervention. Cardiac tamponade requires immediate decompression to relieve pressure on the heart and restore normal function.

D. Assessing for paradoxical blood pressure can provide additional information but does not address the immediate need for intervention.

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Naxlex Comprehensive Predictor Exams

The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?

Correct Answer is B

Explanation

A client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant heart sounds, and is anxious and restless. After Initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement?

Correct Answer is C

Explanation

The nurse is caring for a client with a fractured femur. Following removal of traction and the application of a full-leg cast, which action should the nurse prioritize?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

A client tells the nurse about beginning an exercise program a month ago to lose weight and improve sleep. The client states, "It still takes at least two hours to fall asleep at night." Which action should the nurse implement?

An client who weighs 160 pounds receives a prescription for gentamicin 5 mg/kg/day intravenously in divided doses every 8 hours. How many mg should the nurse administer with each dose? (Enter numerical value only. If rounding is required, round to the nearest whole number.)