A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

"I will call the doctor and get a prescription."

"I will cover the catheter so he cannot see it."

"I will provide more stimulation in his environment."

"Let's wait until tonight to see if he continues this behavior."

Answer and Explanation

The Correct Answer is B

Choice A reason : While consulting with the healthcare provider is important, immediate action is necessary to prevent harm. Waiting for a prescription may delay intervention.

Choice B reason : When a patient frequently attempts to remove their intravenous (IV) catheter, it's essential to address the behavior promptly to prevent potential complications such as catheter dislodgement, infection, or injury. The most appropriate initial response is to cover the catheter to reduce the patient's awareness and access, thereby decreasing the likelihood of tampering.

Choice C reason : Providing more stimulation could be counterproductive if the client is already agitated or confused. The nurse should assess the client's needs and environment to determine the appropriate level of stimulation.

Choice D reason : Waiting without taking action is not advisable as the client may harm themselves by removing the IV catheter. Immediate intervention is required to ensure the client's safety.

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Correct Answer is ["A","B","C","E","F"]

Explanation

Choice A reason : Morphine sulfate is used intravenously in acute heart failure with pulmonary edema because it can reduce preload and afterload, thereby decreasing the work of the heart and improving breathing.

Choice B reason : Administering oxygen is crucial for a client with pulmonary edema to improve oxygenation and relieve symptoms of hypoxia.

Choice C reason : Transporting the client to the coronary care unit is appropriate for continuous monitoring and management of acute heart failure and pulmonary edema.

Choice D reason : While placing the client in a high Fowler's position is recommended to ease breathing, the low Fowler's side-lying position is not typically indicated for pulmonary edema. Therefore, this choice is incorrect.

Choice E reason : Inserting a Foley catheter can help monitor urine output, especially important when administering diuretics like furosemide, and manage fluid status.

Choice F reason : Administering furosemide (Lasix), a diuretic, helps to reduce fluid overload and relieve pulmonary congestion in clients with heart failure and pulmonary edema.

A. Plantar reflex B. Kernig's sign C. Brudzinski's sign D. Sunsetting eyes

Correct Answer is C

Explanation

Choice A reason : The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults¹. However, it is not specifically associated with meningeal irritation.

Choice B reason : Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign².

Choice C reason : Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma².

Choice D reason : Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation³.

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A nurse is caring for a client who frequently attempts to remove his IV catheter. A family member requests that the nurse apply restraints. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","E","F"]

Explanation

A client has undergone surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing an infection. An early critical manifestation of meningeal irritation for which the nurse assesses the client is :

Correct Answer is C

Explanation

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