Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse suspects that a client has increasing intracranial pressure. Which of the following diagnostics does the nurse anticipate will be ordered?
A. esophagogastroduodenoscopy
This is incorrect. Esophagogastroduodenoscopy is a procedure that examines the esophagus, stomach, and duodenum using a flexible tube with a camera. It is not used to diagnoseintracranial pressure.
B. endarterectomy
This is incorrect. Endarterectomy is a surgical procedure that removes plaque from an artery, usually in the neck or leg. It is not used to diagnose intracranial pressure.
C. lumbar puncture
This is incorrect. Lumbar puncture is a procedure that involves inserting a needle into the spinal canal to collect cerebrospinal fluid or administer medication. It is contraindicated in clients with increased intracranial pressure because it can cause brain herniation or bleeding.
D. magnetic resonance imaging
This is correct. Magnetic resonance imaging (MRI) is a noninvasive imaging technique that uses a strong magnetic field and radio waves to produce detailed pictures of the brain and other organs. It can detect changes in brain tissue, blood flow, and fluid accumulation that mayindicate increased intracranial pressure.
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Similar Questions
A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?
A. "Wear an eye patch on the right eye at all times."
A. "Wear an eye patch on the right eye at all times." An eye patch may be recommended alternating between eyes for short periods to relieve diplopia, but wearing it continuously on one eye can lead to eye strain and decreased depth perception.
B. "Implement a schedule to include periods of rest."
B. "Implement a schedule to include periods of rest." Fatigue is a common and debilitating symptom in clients with MS. Scheduling regular rest periods helps prevent overexertion, which can worsen symptoms and increase the risk of relapse.
C. "Engage in a vigorous exercise program."
C. "Engage in a vigorous exercise program." Vigorous exercise may exacerbate MS symptoms, particularly fatigue and heat sensitivity. Instead, a moderate, low-impact exercise program (e.g., swimming, yoga) is more appropriate.
D. "Plan to relax in a hot tub spa each day."
D. "Plan to relax in a hot tub spa each day." Heat can worsen MS symptoms (a phenomenon known as Uhthoff’s sign). Hot environments, such as hot tubs or spas, should be avoided to prevent symptom exacerbation.
Full Explanation
A. "Wear an eye patch on the right eye at all times."
An eye patch may be recommended alternating between eyes for short periods to relieve diplopia, but wearing it continuously on one eye can lead to eye strain and decreased depth perception.
B. "Implement a schedule to include periods of rest."
Fatigue is a common and debilitating symptom in clients with MS. Scheduling regular rest periods helps prevent overexertion, which can worsen symptoms and increase the risk of relapse.
C. "Engage in a vigorous exercise program."
Vigorous exercise may exacerbate MS symptoms, particularly fatigue and heat sensitivity. Instead, a moderate, low-impact exercise program (e.g., swimming, yoga) is more appropriate.
D. "Plan to relax in a hot tub spa each day."
Heat can worsen MS symptoms (a phenomenon known as Uhthoff’s sign). Hot environments, such as hot tubs or spas, should be avoided to prevent symptom exacerbation.
A nurse at a community health clinic is caring for a client who reports a headache and stiff neck. Which of the following actions should the nurse take first?
A. Perform a complete blood count.
Performing a complete blood count is not the priority action for this client, who might have signs of meningitis, a serious infection of the meninges that requires prompt diagnosis andtreatment. This choice is incorrect.
B. Check the client's temperature.
Checking the client's temperature is an important action, but not the first one. The nurse should assess the client's neurological status before taking vital signs to determine the level of consciousness and possible complications of meningitis. This choice is incorrect.
C. Administer an oral analgesic
Administering an oral analgesic is not appropriate for this client, who might have difficulty swallowing or altered mental status due to meningitis. Moreover, this action might mask the symptoms and delay the diagnosis and treatment of the infection. This choice is incorrect.
D. Evaluate the client's neurological status.
Evaluating the client's neurological status is the first and most important action for this client, who has two classic signs of meningitis: headache and stiff neck. The nurse should assess for other signs, such as photophobia, nausea, vomiting, fever, and rash, and report them to the provider immediately. This choice is correct.
A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?
A. Tachycardia
Tachycardia is not an indication of increased ICP, but rather a compensatory mechanism to maintain cerebral perfusion pressure in response to elevated ICP. As the ICP rises, the heart ratewill eventually decrease due to increased vagal stimulation from increased intrathoracic pressure. This choice is incorrect.
B. Restlessness
Restlessness is an early sign of increased ICP, indicating decreased cerebral oxygenation and impaired cognition. The nurse should monitor the client's level of consciousness and report any changes to the provider promptly. This choice is correct.
C. Hypotension
Hypotension is not an indication of increased ICP, but rather a sign of shock or hemorrhage that can lead to decreased cerebral perfusion pressure and brain ischemia. The nurse shouldmonitor the client's blood pressure and report any hypotension to the provider immediately. This choice is incorrect.
D. Amnesia
Amnesia is not an indication of increased ICP, but rather a result of brain injury that affects memory and learning. The nurse should assess the client's orientation and recall and provide frequent reminders and cues to enhance memory retention. This choice is incorrect.