Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless.
Which of the following assessments should the nurse perform first?
A. Motor responses.
Motor responses are not the first assessment that should be performed.
B. Blood glucose.
Blood glucose is not the first assessment that should be performed.
C. Urinary output.
Urinary output is not the first assessment that should be performed.
D. Blood pressure.
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure. The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
A change in behavior such as agitation and restlessness in a client with a traumatic brain injury can be a sign of increased intracranial pressure.
The nurse should first assess the client’s blood pressure as an increase in blood pressure can be an indicator of increased intracranial pressure.
Motor responses are not the first assessment that should be performed.
Blood glucose is not the first assessment that should be performed.
Urinary output is not the first assessment that should be performed.
Similar Questions
A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes.
Which of the following statements by the client indicates the effectiveness of the teaching?
A. "I should apply antibiotic ointment to the lesions.".
Choice A is incorrect because antibiotic ointment is not used to treat genital herpes lesions. Antiviral medication is used to manage symptoms and prevent outbreaks.
B. "I should expect my lesions to resolve in 6 weeks.".
This statement indicates that the client understands that genital herpes lesions can take time to heal and that they may not resolve immediately.
C. "I should use natural skin condoms during sexual intercourse.".
Choice C is incorrect because natural skin condoms are not effective in preventing the spread of genital herpes. Latex condoms should be used during sexual intercourse to reduce the risk of transmission.
D. "I should expect to take my medication for 3 weeks.".
Choice D is incorrect because the duration of antiviral medication treatment for genital herpes varies and may be longer than 3 weeks. It’s important for the client to follow their healthcare provider’s instructions for taking medication.
E. "I should expect to take my medication for 3 weeks.".
Full Explanation
This statement indicates that the client understands that genital herpes lesions can take time to heal and that they may not resolve immediately.
Choice A is incorrect because antibiotic ointment is not used to treat genital herpes lesions.
Antiviral medication is used to manage symptoms and prevent outbreaks.
Choice C is incorrect because natural skin condoms are not effective in preventing the spread of genital herpes.
Latex condoms should be used during sexual intercourse to reduce the risk of transmission.
Choice D is incorrect because the duration of antiviral medication treatment for genital herpes varies and may be longer than 3 weeks.
It’s important for the client to follow their healthcare provider’s instructions for taking medication.
A nurse is caring for a client who has a sealed radiation implant.
Which of the following actions should the nurse take?
A. Limit family member visits 30 min per day.
This statement indicates that the nurse understands the importance of limiting the exposure of family members to radiation from the sealed implant.
B. Give the dosimeter badge to the oncoming nurse at the end of the shift.
Choice B is incorrect because the dosimeter badge should not be given to the oncoming nurse at the end of the shift. The dosimeter badge is used to measure an individual’s exposure to radiation and should be worn by the same person throughout their shift.
C. Apply a second pair of gloves before touching the client's implant if it dislodges.
Choice C is incorrect because if the client’s implant dislodges, the nurse should not touch it with their hands, even if they are wearing gloves. The nurse should follow the facility’s protocol for handling dislodged implants.
D. Remove soiled linens from the room after each change.
Choice D is incorrect because soiled linens from a client with a sealed radiation implant do not need to be removed from the room after each change. The linens can be handled according to standard precautions.
Full Explanation
This statement indicates that the nurse understands the importance of limiting the exposure of family members to radiation from the sealed implant.
Choice B is incorrect because the dosimeter badge should not be given to the oncoming nurse at the end of the shift.
The dosimeter badge is used to measure an individual’s exposure to radiation and should be worn by the same person throughout their shift.
Choice C is incorrect because if the client’s implant dislodges, the nurse should not touch it with their hands, even if they are wearing gloves.
The nurse should follow the facility’s protocol for handling dislodged implants.
Choice D is incorrect because soiled linens from a client with a sealed radiation implant do not need to be removed from the room after each change.
The linens can be handled according to standard precautions.
A nurse is caring for a client who is receiving a blood transfusion.
The nurse observes that the client has bounding peripheral pulses, hypertension, and distended jugular veins.
The nurse should anticipate administering which of the following prescribed medications?
A. Diphenhydramine.
Choice A is incorrect because diphenhydramine is an antihistamine medication that is not used to treat fluid overload.
B. Furosemide.
“Furosemide.” The nurse should anticipate administering furosemide because the client’s symptoms of bounding peripheral pulses, hypertension, and distended jugular veins may indicate fluid overload. Furosemide is a diuretic medication that can help reduce fluid overload by increasing urine output.
C. Acetaminophen.
Choice C is incorrect because acetaminophen is a pain reliever and fever reducer that is not used to treat fluid overload.
D. Pantoprazole.
Choice D is incorrect because pantoprazole is a proton pump inhibitor that is used to treat acid reflux and stomach ulcers, not fluid overload.
Full Explanation
“Furosemide.” The nurse should anticipate administering furosemide because the client’s symptoms of bounding peripheral pulses, hypertension, and distended jugular veins may indicate fluid overload.
Furosemide is a diuretic medication that can help reduce fluid overload by increasing urine output.
Choice A is incorrect because diphenhydramine is an antihistamine medication that is not used to treat fluid overload.
Choice C is incorrect because acetaminophen is a pain reliever and fever reducer that is not used to treat fluid overload.
Choice D is incorrect because pantoprazole is a proton pump inhibitor that is used to treat acid reflux and stomach ulcers, not fluid overload.