Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who is 4 hr postoperative following a craniotomy for the treatment of a benign brain tumor. Which of the following findings should the nurse identify as the priority?
A. 15 mL of drainage in Hemovac
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
B. Periorbital ecchymosis
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
C. Nonreactive pupils
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
D. Hgb 11 g/dL
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Drainage in the Hemovac is an expected finding postoperatively and is not as urgent as nonreactive pupils.
Choice B rationale:
Periorbital ecchymosis (bruising around the eyes) is not uncommon after a craniotomy and is not as urgent as nonreactive pupils.
Choice C rationale:
Nonreactive pupils can indicate a neurological emergency, such as increased intracranial pressure or potential damage to the cranial nerves. This finding requires immediate attention to prevent further complications.
Choice D rationale:
Hemoglobin level of 11 g/dL is within a normal range and is not a priority concern.
Similar Questions
A nurse is speaking with a client who is experiencing a situational crisis following the sudden death of his partner. Which of the following questions should the nurse ask the client first?
A. "Who do you talk to when you feel overwhelmed?"
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
B. "Are you thinking about harming yourself?"
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
C. "Can we talk about how your partner's death has affected you?"
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
D. "What do you usually do to calm your thoughts?"
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
Full Explanation
Choice A rationale:
Asking who the client talks to when overwhelmed is important, but assessing for suicidal thoughts is more urgent.
Choice B rationale:
Assessing the client's risk for harm to themselves is the priority when dealing with a person in crisis. This helps determine the need for immediate intervention to ensure their safety.
Choice C rationale:
Discussing the impact of the partner's death can be therapeutic, but ensuring immediate safety is the priority.
Choice D rationale:
Inquiring about coping strategies is important, but assessing for suicidal thoughts takes precedence.
A nurse is providing teaching to the parents of a school-age child who has a new prescription for somatropin to treat growth hormone deficiency. Which of the following statements should the nurse make?
A. "This medication might cause hypoglycemia."
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
B. "Place this medication under your child's tongue."
Somatropin is usually administered via injection, not under the tongue.
C. "This medication might cause ringing in your child's ears,"
Ringing in the ears is not a common side effect of somatropin.
D. "Measure your child's height monthly while taking this medication."
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
Full Explanation
Choice A rationale:
Somatropin can affect glucose metabolism and may lead to hypoglycemia. Parents should be aware of this potential side effect and monitor their child's blood sugar levels.
Choice B rationale:
Somatropin is usually administered via injection, not under the tongue.
Choice C rationale:
Ringing in the ears is not a common side effect of somatropin.
Choice D rationale:
Monitoring height monthly is important, but explaining the potential for hypoglycemia is more relevant to the immediate safety of the child.
A nurse is assessing a client who has a new diagnosis of major depressive disorder.
Which of the following client statements should the nurse expect?
A. "I feel like my mood has been all over the place."
Rapid mood swings are not a defining characteristic of major depressive disorder.
B. "I recently started hearing voices in my head."
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
C. “I cannot trust you enough to tell you how I feel."
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
D. "just don't feel like doing things I usually enjoy."
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
E. "just don't feel like doing things I usually enjoy."
Full Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.