Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who was admitted for observation following a head injury. Which of the following findings by the nurse indicates the client is experiencing increased intracranial pressure?
A. Pin-point pupils
Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light.
B. Irritability
Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C. Pallor
Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Decreased blood pressure
Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
A. Pinpoint pupils are more commonly associated with opioid intoxication or damage to the pons rather than increased intracranial pressure (ICP). Increased ICP typically causes pupils to become dilated and sluggish or nonreactive to light
B. Irritability can be an early sign of increased intracranial pressure. As pressure within the skull rises, it can affect the brain's ability to function normally, leading to changes in behavior such as restlessness, agitation, or irritability.
C. Pallor is not directly associated with increased intracranial pressure. It might indicate other issues such as anemia or poor circulation, but it is not a specific sign of increased ICP.
D. Increased intracranial pressure typically leads to hypertension (increased blood pressure) as part of the Cushing's triad, which includes hypertension, bradycardia, and irregular respirations. Decreased blood pressure would not be a typical finding associated with increased ICP.
Similar Questions
A nurse is caring for a client who recently gave birth to her first child. The newborn is crying and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?
A. "I'll take him back to the nursery, so you can get some rest."
B. "Let me show you how to swaddle and cuddle him, then you try."
This response acknowledges the client's concern and offers support and guidance. By demonstrating and encouraging the client to participate in swaddling and cuddling the newborn, the nurse promotes bonding, provides a practical solution for soothing the baby, and empowers the client to actively engage in caring for her child.
C. "Babies need to cry soon after they are born to develop their lungs.
D. "If I turn him on his side, maybe he'll go back to sleep."
Full Explanation
This response acknowledges the client's concern and offers support and guidance. By demonstrating and encouraging the client to participate in swaddling and cuddling the newborn, the nurse promotes bonding, provides a practical solution for soothing the baby, and empowers the client to actively engage in caring for her child.
A nurse is supervising an assistive personnel (AP) who is providing client care. The nurse should identify that which of the following actions by the AP demonstrates effective use of supplies?
A. Wears an N95 mask when bathing a client who has Clostridium difficile
Wearing an N95 mask when bathing a client with Clostridium difficile is important, but it is not related to effective use of supplies.
B. Disposes of contaminated sheets in a linen bag
The nurse should identify that disposing of contaminated sheets in a linen bag demonstrates effective use of supplies.
C. Wears clean gloves when performing oral hygiene
Wearing clean gloves when performing oral hygiene is standard practice for infection control and not specific to the use of supplies.
D. Empties the sharps container when it is full The correct answer is B
Empting the sharps container when it is full is also important, but it is not related to effective use of supplies.
Full Explanation
The nurse should identify that disposing of contaminated sheets in a linen bag demonstrates effective use of supplies.
Wearing an N95 mask when bathing a client with Clostridium difficile is important, but it is not related to effective use of supplies.
Wearing clean gloves when performing oral hygiene is standard practice for infection control and not specific to the use of supplies.
Empting the sharps container when it is full is also important, but it is not related to effective use of supplies.
A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?
A. Clam chowder
The nurse should avoid including clam chowder, pulled-pork sandwich, and shrimp salad in the client's menu
B. Pulled-pork sandwich
The nurse should avoid including clam chowder, pulled-pork sandwich, and shrimp salad in the client's menu
C. Shrimp salad
The nurse should avoid including clam chowder, pulled-pork sandwich, and shrimp salad in the client's menu
D. Roasted salmon
Kosher dietary laws prohibit the consumption of shellfish (such as clam chowder and shrimp salad) and pork (such as a pulled-pork sandwich).
Full Explanation
Kosher dietary laws prohibit the consumption of shellfish (such as clam chowder and shrimp salad) and pork (such as a pulled-pork sandwich). Therefore, the nurse should avoid including clam chowder, pulled-pork sandwich, and shrimp salad in the client's menu.
Instead, offering foods that comply with kosher guidelines, such as roasted salmon, ensures that the client's dietary needs and preferences are respected.