Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Amnesia.
This is not necessarily indicative of increased ICP
B. Tachycardia.
This is not necessarily indicative of increased ICP
C. Altered level of consciousness.
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
D. Hypotension.
Hypotension is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
Similar Questions
A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, by which of the following times should the nurse ensure the patient receives breakfast?
A. 0720.
0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.
B. 0815.
0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.
C. 0745.
0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.
D. 0730.
0730.is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.
Full Explanation
0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.
Choice A. 0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.
Choice B. 0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.
Choice D. 0730. is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.
A nurse is caring for four clients at an urgent care center. Which of the following clients should the nurse suspect has been physically abused?
A. 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on tablecloth, spilling a cup of tea on himself.
A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself: Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.
B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.
B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle: A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.
C. 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows.
C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows: Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.
D. 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water.
D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water: While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.
Full Explanation
Answer: B. 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle.
Rationale:
A) 3-year-old toddler with scalding burns over the face and chest reportedly sustained when the child pulled on a tablecloth, spilling a cup of tea on himself:
Scalding burns in young children can be accidental, especially if the burns are consistent with typical patterns seen in such accidents. However, burns covering a large area, especially on the face and chest, may warrant further investigation to rule out abuse, particularly if the explanation seems inconsistent with the injury.
B) 6-year-old child who has a spiral fracture of the tibia and fibula, which reportedly occurred while riding a bicycle:
A spiral fracture is often associated with a twisting or rotational force, which is less common in typical bicycle accidents. Spiral fractures in children can be indicative of physical abuse, particularly if the explanation for the injury does not fit the typical mechanisms of injury associated with the reported activity. This type of fracture should prompt a thorough evaluation for possible abuse.
C) 14-month-old toddler who is reportedly learning to walk and has several bruises on bony prominences of the lower legs and elbows:
Bruises on bony prominences are common in toddlers who are learning to walk and are prone to minor falls. This pattern of bruising is usually consistent with typical developmental activities rather than abuse. However, repeated or severe bruising should still be evaluated carefully.
D) 9-month-old infant who sustained near drowning when he reportedly climbed into the tub and turned on the water:
While near drowning in an infant is a serious concern, it is less likely to be related to physical abuse if the explanation involves an accidental event. A thorough assessment is necessary to ensure safety and prevent further incidents, but the described scenario is not as indicative of abuse as a spiral fracture.
A nurse is collecting data on a client who is experiencing chronic stress. Which of the following is an expected finding?
A. Hypotension
B. Increased cognitive awareness
C. Viral infection
Chronic stress can suppress the immune system, making it easier for viral infections to occur. Hypotension is not a common finding in chronic stress, as the body usually responds to stress by releasing adrenaline, which can increase blood pressure. Increased cognitive awareness and increased energy can occur in response to acute stress, but chronic stress can lead to mental and physical exhaustion.
D. Increased energy
Full Explanation
Chronic stress can suppress the immune system, making it easier for viral infections to occur. Hypotension is not a common finding in chronic stress, as the body usually responds to stress by releasing adrenaline, which can increase blood pressure. Increased cognitive awareness and increased energy can occur in response to acute stress, but chronic stress can lead to mental and physical exhaustion.