Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a contusion of the brainstem and reports thirst. The client's urinary output was 4,000 mL over the past 24 hours. The nurse should anticipate a prescription for which of the following intravenous (IV) medications?
A. Epinephrine
Epinephrine is primarily used in emergency situations for its vasoconstrictive and bronchodilatory effects, particularly in cases of anaphylaxis or cardiac arrest. It is not typically used to manage symptoms associated with brainstem contusions or to regulate urinary output.
B. Furosemide
Furosemide is a loop diuretic commonly prescribed to reduce fluid retention in conditions such as heart failure or renal disease. Given that the client has already produced a large volume of urine (4,000 mL in 24 hours, which is above the normal range of 800 to 2,000 milliliters per day), administering furosemide would not be appropriate as it would likely exacerbate the excessive urinary output.
C. Nitroprusside
Nitroprusside is a potent vasodilator used to treat acute hypertensive crises. It has no role in the management of thirst or regulation of urinary output and is not indicated for the treatment of brainstem contusions.
D. Desmopressin
Desmopressin is a synthetic analogue of the naturally occurring antidiuretic hormone vasopressin. It is used to treat conditions characterized by excessive urination, such as diabetes insipidus, and to manage polyuria and polydipsia (excessive thirst) following head trauma or surgery in the pituitary region. In the context of a brainstem contusion with a reported high urinary output, desmopressin would be the appropriate medication to prescribe to reduce urine volume and address the client's thirst.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Epinephrine is primarily used in emergency situations for its vasoconstrictive and bronchodilatory effects, particularly in cases of anaphylaxis or cardiac arrest. It is not typically used to manage symptoms associated with brainstem contusions or to regulate urinary output.
Choice B reason: Furosemide is a loop diuretic commonly prescribed to reduce fluid retention in conditions such as heart failure or renal disease. Given that the client has already produced a large volume of urine (4,000 mL in 24 hours, which is above the normal range of 800 to 2,000 milliliters per day), administering furosemide would not be appropriate as it would likely exacerbate the excessive urinary output.
Choice C reason: Nitroprusside is a potent vasodilator used to treat acute hypertensive crises. It has no role in the management of thirst or regulation of urinary output and is not indicated for the treatment of brainstem contusions.
Choice D reason: Desmopressin is a synthetic analogue of the naturally occurring antidiuretic hormone vasopressin. It is used to treat conditions characterized by excessive urination, such as diabetes insipidus, and to manage polyuria and polydipsia (excessive thirst) following head trauma or surgery in the pituitary region. In the context of a brainstem contusion with a reported high urinary output, desmopressin would be the appropriate medication to prescribe to reduce urine volume and address the client's thirst.
Similar Questions
A nurse is admitting a client who has meningitis. Which of the following findings should the nurse expect?
A. Petechiae on the chest
Petechiae on the chest are small, red or purple spots caused by bleeding into the skin and may be associated with various conditions, including infections. However, they are not a common finding in meningitis. Meningitis typically presents with symptoms related to inflammation of the meninges, the protective membranes covering the brain and spinal cord.
B. Bradycardia
Bradycardia, which is a slower than normal heart rate, is not a typical symptom of meningitis. While meningitis can affect various bodily functions, the classic symptoms are fever, headache, and neck stiffness, not changes in heart rate.
C. Intermittent headache
Intermittent headache could be associated with meningitis, but the headaches that accompany meningitis are usually constant and severe due to the inflammation of the meninges. They are not typically described as intermittent.
D. Photophobia
Photophobia, or light sensitivity, is a common finding in meningitis. The inflammation of the meninges can lead to an increased sensitivity to light, causing discomfort or pain when the patient is exposed to bright lights. This symptom, along with headache, neck stiffness, and fever, helps to distinguish meningitis from other conditions.
Full Explanation
Choice A reason: Petechiae on the chest are small, red or purple spots caused by bleeding into the skin and may be associated with various conditions, including infections. However, they are not a common finding in meningitis. Meningitis typically presents with symptoms related to inflammation of the meninges, the protective membranes covering the brain and spinal cord.
Choice B reason: Bradycardia, which is a slower than normal heart rate, is not a typical symptom of meningitis. While meningitis can affect various bodily functions, the classic symptoms are fever, headache, and neck stiffness, not changes in heart rate.
Choice C reason: Intermittent headache could be associated with meningitis, but the headaches that accompany meningitis are usually constant and severe due to the inflammation of the meninges. They are not typically described as intermittent.
Choice D reason: Photophobia, or light sensitivity, is a common finding in meningitis. The inflammation of the meninges can lead to an increased sensitivity to light, causing discomfort or pain when the patient is exposed to bright lights. This symptom, along with headache, neck stiffness, and fever, helps to distinguish meningitis from other conditions.
The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator?
A. Areas around pins are dry.
Dry areas around the pins can be a normal finding if the pin sites are healing properly. It indicates that there is no excessive moisture that could promote bacterial growth and infection. However, the nurse should continue to monitor for any signs of redness, swelling, or pain that could indicate a developing infection.
B. Crusts around pins.
Crusts around the pins are typically a sign of dried exudate, which can be part of the normal healing process. The crusts should be monitored and cleaned according to the healthcare facility's protocol to prevent infection. If the crusts are accompanied by other signs of infection, such as redness, warmth, or purulent drainage, they should be reported to the healthcare provider.
C. Purulent drainage around pins.
Purulent drainage around the pins is a sign of infection and should be reported immediately to the unit care coordinator. Infections at pin sites can lead to complications such as osteomyelitis, delayed healing, or even systemic infection. Prompt intervention with appropriate cleaning and possibly antibiotics is necessary to prevent further complications.
D. Absence of pain at the site.
The absence of pain at the site can be a normal finding and is not typically a cause for concern unless there is an expectation of pain based on the patient's condition or recent procedures. However, a complete lack of sensation could indicate nerve damage or other issues, so the nurse should assess for other signs of neurovascular compromise and report any concerns to the healthcare provider.
Full Explanation
Choice A reason: Dry areas around the pins can be a normal finding if the pin sites are healing properly. It indicates that there is no excessive moisture that could promote bacterial growth and infection. However, the nurse should continue to monitor for any signs of redness, swelling, or pain that could indicate a developing infection.
Choice B reason: Crusts around the pins are typically a sign of dried exudate, which can be part of the normal healing process. The crusts should be monitored and cleaned according to the healthcare facility's protocol to prevent infection. If the crusts are accompanied by other signs of infection, such as redness, warmth, or purulent drainage, they should be reported to the healthcare provider.
Choice C reason: Purulent drainage around the pins is a sign of infection and should be reported immediately to the unit care coordinator. Infections at pin sites can lead to complications such as osteomyelitis, delayed healing, or even systemic infection. Prompt intervention with appropriate cleaning and possibly antibiotics is necessary to prevent further complications.
Choice D reason: The absence of pain at the site can be a normal finding and is not typically a cause for concern unless there is an expectation of pain based on the patient's condition or recent procedures. However, a complete lack of sensation could indicate nerve damage or other issues, so the nurse should assess for other signs of neurovascular compromise and report any concerns to the healthcare provider.
A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy?
A. Constipation
Constipation can be a side effect of many cancer treatments, including radiation therapy. However, it is not commonly associated with targeted radiation therapy to the neck. Constipation is more often related to opioid pain medications, decreased physical activity, or dietary changes that a patient may experience during cancer treatment.
B. Decreased tear production
Decreased tear production is not a typical side effect of targeted radiation therapy to the neck. This condition, known as dry eye syndrome, is more commonly associated with radiation therapy that affects the eye or orbital area directly.
C. Mouth ulcers
Mouth ulcers, also known as mucositis, are a common adverse effect of radiation therapy to the neck. Radiation can damage the mucosal lining of the mouth, leading to painful sores that can affect a patient's ability to eat, speak, and swallow. These ulcers typically develop one to two weeks after starting treatment and may persist for some time after the treatment ends.
D. Peripheral neuropathy
Peripheral neuropathy, which involves damage to the peripheral nerves and often results in symptoms like numbness, tingling, or pain in the hands and feet, is not a common side effect of radiation therapy to the neck. It is more frequently associated with certain chemotherapeutic agents or radiation therapy to areas of the body where peripheral nerves are located.
Full Explanation
Choice A reason: Constipation can be a side effect of many cancer treatments, including radiation therapy. However, it is not commonly associated with targeted radiation therapy to the neck. Constipation is more often related to opioid pain medications, decreased physical activity, or dietary changes that a patient may experience during cancer treatment.
Choice B reason: Decreased tear production is not a typical side effect of targeted radiation therapy to the neck. This condition, known as dry eye syndrome, is more commonly associated with radiation therapy that affects the eye or orbital area directly.
Choice C reason: Mouth ulcers, also known as mucositis, are a common adverse effect of radiation therapy to the neck. Radiation can damage the mucosal lining of the mouth, leading to painful sores that can affect a patient's ability to eat, speak, and swallow. These ulcers typically develop one to two weeks after starting treatment and may persist for some time after the treatment ends.
Choice D reason: Peripheral neuropathy, which involves damage to the peripheral nerves and often results in symptoms like numbness, tingling, or pain in the hands and feet, is not a common side effect of radiation therapy to the neck. It is more frequently associated with certain chemotherapeutic agents or radiation therapy to areas of the body where peripheral nerves are located.