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Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

0800: Heart rate 130 beats/minute, blood pressure 190/90 mm Hg; 1200: heart rate 136 beats/minute, blood pressure 200/100 mm Hg, Kussmaul respirations.

0800: Heart rate 55 beats/minute, blood pressure 160/70 mm Hg; 1200: heart rate 50 beats/minute, blood pressure 194/70 mm Hg, irregular respirations.

0800: Heart rate 110 beats/minute, blood pressure 130/70 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 110/70 mm Hg, shallow respirations.

0800: Heart rate 70 beats/minute, blood pressure 120/60 mm Hg; 1200: heart rate 100 beats/minute, blood pressure 90/60 mm Hg, rapid respirations.

Answer and Explanation

The Correct Answer is B

A. Elevated heart rate and BP may indicate stress or pain, but Kussmaul respirations are more typical of metabolic acidosis (e.g., DKA), not increased ICP.

B. Bradycardia, widening pulse pressure (increased systolic with stable diastolic), and irregular respirations are signs of Cushing’s triad, a late but classic indicator of increased ICP requiring immediate reporting.

C. Vital signs here are stable and within expected ranges; shallow respirations may be related to sedation or fatigue but not increased ICP.

D. This pattern suggests hypotension and compensatory tachycardia, more consistent with hypovolemia or shock than increased ICP.

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Correct Answer is ["C","D","E","F","H"]

Explanation

A. Perform aggressive weight bearing exercises: Aggressive weight-bearing exercises may place too much strain on the joints, especially for someone with RA. Low-impact activities, such as swimming or walking, are generally recommended to avoid exacerbating joint damage or pain.

B. Anticipate dry eyes and mouth; no intervention is needed: While dry eyes and mouth can occur in autoimmune diseases like RA, particularly if the client has secondary Sjögren's syndrome, they should not be ignored. The nurse should advise the client to seek treatment for these symptoms, as interventions can provide relief.

C. Take hot showers to help relieve stiffness: Warm showers or baths can help reduce the stiffness and pain associated with rheumatoid arthritis (RA) by relaxing muscles and improving circulation. This can be an effective method to manage the morning stiffness that the client experiences.

D. Observe skin for any lesions: Skin lesions can be a result of certain medications or the disease process itself. RA treatment, particularly with medications like methotrexate or biologics, can increase the risk of skin issues, and regular monitoring is important for early identification.

E. Watch for gastrointestinal upset with medication administration: NSAIDs like ibuprofen, which the client is taking for pain, can cause gastrointestinal issues such as ulcers or irritation. Monitoring for these symptoms is important to avoid complications related to the medication.

F. Discuss body image feelings with a trusted friend or therapist: The chronic nature of RA, along with potential joint deformities and limitations, can impact body image. Discussing these feelings with a trusted person or therapist can help the client manage the psychological aspects of living with a chronic condition.

G. Avoid fluids, to decrease trips to the bathroom: Reducing fluid intake could lead to dehydration, which may cause other complications. The client should be encouraged to drink adequate fluids, despite more frequent trips to the bathroom, to stay properly hydrated.

H. Prioritize rest, with short periods of activity: RA can cause joint fatigue and pain. It’s important to balance periods of rest with light, non-strenuous activities to reduce stress on the joints while maintaining some level of mobility. This can help manage energy levels and minimize joint strain.

A. Abdominal cramping. B. Low grade fever. C. Bruising of the skin. D. Bloody emesis.

Correct Answer is D

Explanation

A. Abdominal cramping: Abdominal cramping can be a common symptom of gastritis and may not necessarily require immediate reporting unless it is severe or accompanied by other concerning symptoms.

B. Low grade fever: A low-grade fever can occur with gastritis as part of the inflammatory response, but it is not an immediate concern unless it persists or worsens. It is generally not as urgent as other symptoms.

C. Bruising of the skin: Bruising is not a typical symptom of gastritis. It may be indicative of a bleeding disorder or other underlying issues unrelated to the gastrointestinal system. However, it is not directly associated with gastritis.

D. Bloody emesis: Bloody emesis (vomiting blood) is a critical sign that indicates possible gastrointestinal bleeding, which can occur with severe gastritis. This is an emergency situation and should be reported immediately as it requires urgent medical attention.

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Which client's vital signs indicating increased intracranial pressure (ICP) should the nurse report to the healthcare provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The client has received a medical diagnosis of rheumatoid arthritis (RA). The client should receive education about living and managing her condition and how to minimize disease complications. Which education should be given to the client by the nurse? Select all that apply.

Correct Answer is ["C","D","E","F","H"]

Explanation

The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?

Correct Answer is D

Explanation

The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel (UAP) working on a rehabilitation unit. The UAP asks the nurse how to safely move a physically disabled client from the wheelchair to a bed. Which action should the nurse recommend?

Exhibits 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.

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The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

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