Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
You are monitoring the vital signs of an 74yrold man who was admitted for a head injury after he tripped and fell at home. He takes anticoagulants for atrial fibrillation. On arrival his vital signs were stable at BP 150/86, pulse 84, respirations 14/min, but his family reported that he was more restless than usual. He lives alone after his wife passed away. 2 hours after admission, his vital
signs are now BP 166/74, pulse 54, respirations 11/min. He is now quiet and appears sleepy. He is on 2L nasal cannula and has been placed on neutropenic precautions.
This question is an excerpt from Nurse Dive's nursing test bank - Ati med surg adult care 2 proctored exam. Take the full exam now
Full Explanation
He is now quiet and appears sleepy. This is correct because it indicates a change in the level of consciousness, which could be a sign of increased intracranial pressure or bleeding in the brain.
Similar Questions
A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)
A. Furnish restraints at the bedside.
Furnish restraints at the bedside. This is incorrect because restraints are not recommended for clients with seizure disorder as they can increase agitation, injury, and aspiration risk. Instead, the nurse should protect the client from harm by removing any objects that could cause injury and padding the side rails if needed.
B. Elevate the side rails near the head when the client is in bed.
Elevate the side rails near the head when the client is in bed. This is correct because it can prevent the client from falling out of bed during a seizure and reduce injury risk.
C. Place the bed in the lowest position
Place the bed in the lowest position. This is correct because it can reduce injury risk if the client falls out of bed during a seizure.
D. Provide a suction setup at the bedside.
Provide a suction setup at the bedside. This is correct because it can help clear secretions and prevent aspiration after a seizure.
E. Keep an oxygen setup at the bedside.
Seizures can cause hypoxia, especially if prolonged. Having oxygen readily available ensures quick intervention to support oxygenation post-seizure.
A nurse receives a postsurgical endarterectomy client, what is the priority action for the nurse to take?
A. Ambulate 3 times a shift
Ambulate 3 times a shift: This is incorrect because ambulation is not a priority action for a postsurgical endarterectomy client. Ambulation may increase the risk of bleeding or hematoma formation at the surgical site.
B. Perform a vascular assessment
Perform a vascular assessment: This is correct because a vascular assessment is essential to monitor the patency of the graft and the perfusion of the affected extremity. The nurse should assess the pulses, color, temperature, sensation, and movement of the limb every hour for the first 24 hours and then every 4 hours thereafter.
C. Assist to the restroom
Assist to the restroom: This is incorrect because assisting to the restroom is not a priority action for a postsurgical endarterectomy client. The client may have a urinary catheter in place to prevent bladder distension and pressure on the surgical site.
D. Administer pain medications
Administer pain medications: This is incorrect because administering pain medications is not a priority action for a postsurgical endarterectomy client. Pain management is important, but it is not as urgent as assessing the vascular status of the graft and the limb.
A nurse is providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?
A. Provide client supervision.
Provide client supervision. This is correct because clients with Parkinson's disease are at risk of falls, aspiration, and medication errors. They need supervision to ensure their safety andwellbeing.
B. Leave the television on continuously.
Leave the television on continuously. This is incorrect because continuous noise andstimulation can aggravate the symptoms of Parkinson's disease, such as tremors, rigidity, and anxiety. The client needs a quiet and calm environment.
C. Speak loudly to the client
Speak loudly to the client. This is incorrect because speaking loudly can be perceived as shouting or anger by the client. The client may have difficulty speaking, but not hearing. The nurse should speak clearly, slowly, and in a normal tone of voice.
D. Limit client physical activity.
Limit client physical activity. This is incorrect because physical activity can help maintain muscle strength, balance, and coordination in clients with Parkinson's disease. The nurse should encourage the client to exercise regularly and provide assistance as needed.