Which pieces of information link up correctly?

Nausea and vomiting: an indication of a diffuse brain stem injury.

Nuchal rigidity: neck stiffness due to meningeal edema.

Bilateral fixed and dilated pupils: an indication of a cerebellar brain attack.

Brudzinski’s sign: an indication of viral meningitis.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Nausea and vomiting can be caused by various conditions, including gastrointestinal issues and brain injuries, but they are not specifically indicative of a diffuse brain stem injury.
Choice B rationale
Nuchal rigidity, or neck stiffness, is a classic sign of meningeal irritation, often due to meningeal edema in conditions like meningitis.
Choice C rationale
Bilateral fixed and dilated pupils are more commonly associated with severe brain injury or increased intracranial pressure, not specifically a cerebellar brain attack.
Choice D rationale
Brudzinski’s sign is a physical exam finding indicative of meningeal irritation, commonly seen in bacterial meningitis, not specifically viral meningitis.

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Correct Answer is A

Explanation

Choice A rationale
Enlarged liver (hepatomegaly) and peripheral edema are common clinical manifestations of right heart failure (RHF). RHF leads to congestion of systemic circulation, causing fluid accumulation in the liver and peripheral tissues.
Choice B rationale
Crackles in the lungs are more commonly associated with left-sided heart failure, where fluid backs up into the pulmonary circulation, leading to pulmonary edema.
Choice C rationale
A dry hacking cough is not a typical symptom of right heart failure. It is more commonly associated with respiratory conditions such as asthma or bronchitis.
Choice D rationale
Altered mentation with pinpoint pupils is not a characteristic of right heart failure. These symptoms are more indicative of neurological conditions or opioid overdose.

A. Administering supplemental oxygen. B. Encouraging the client to use an incentive spirometer. C. Administering a bronchodilator as prescribed. D. Positioning the client in high Fowler’s position.

Correct Answer is A

Explanation

Choice A rationale
Administering supplemental oxygen is the priority intervention for a client with COPD who has an oxygen saturation of 88% on room air. This low oxygen saturation indicates hypoxemia, which requires immediate correction to prevent further respiratory distress.
Choice B rationale
Encouraging the client to use an incentive spirometer is important for lung expansion and preventing atelectasis, but it is not the priority intervention in this scenario. The immediate concern is to correct the hypoxemia.
Choice C rationale
Administering a bronchodilator as prescribed is important for managing COPD symptoms, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.
Choice D rationale
Positioning the client in high Fowler’s position can help improve breathing, but the priority intervention is to correct the hypoxemia by administering supplemental oxygen.

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Which pieces of information link up correctly?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which clinical manifestations would the nurse expect to find during their assessment of a patient with right heart failure (RHF)?

Correct Answer is A

Explanation

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased shortness of breath and a productive cough. The nurse notes the client’s oxygen saturation is 88% on room air. Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

A client with diabetes mellitus presents with a foot ulcer that is not healing. Which of the following factors could be contributing to the delayed healing?

A nurse is providing education to a client with newly diagnosed type 2 diabetes mellitus. Which statement by the client indicates a need for further teaching?

A nurse is caring for a client with chronic kidney disease (CKD) who presents with hyperkalemia. Which of the following interventions should the nurse implement first?

A man, diagnosed with alcoholic liver disease and cirrhosis, presents to his healthcare provider for treatment. He is complaining of increased blood glucose, blurred vision, and cannot remember his birth date or age. The nurse notes that he has asterixis. These signs are most likely due to:

A nurse is assessing a client with a history of hypertension who presents with a severe headache, blurred vision, and confusion. The nurse should prioritize which of the following actions?

A nurse is assessing a client with suspected meningitis. Which of the following symptoms would most likely indicate meningitis?

A client with a temperature of 39°C (102.2°F) and a rash is being evaluated. Which condition should the nurse consider?