Exhibits

Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

Course breath sounds

Irritability

Seizure activity

Decreased level of consciousness

Bradycardia

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"}}

Coarse breath sounds are typically associated with respiratory distress, indicating fluid or secretions in the airways.

Irritability can be a sign of both cerebral edema and respiratory distress as it may stem from hypoxia or increased intracranial pressure.

Seizure activity is more specifically related to cerebral edema, which can increase intracranial pressure and provoke seizures.

Decreased level of consciousness can occur in both conditions: cerebral edema (due to increased intracranial pressure) and respiratory distress (due to hypoxia).

Bradycardia is more indicative of cerebral edema, especially when associated with increased intracranial pressure and resultant autonomic dysregulation.

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Correct Answer is A

Explanation

A. Understanding what the voices are saying is the most important initial step in assessing auditory hallucinations. This information helps the PN gauge the content of the hallucinations, which is crucial for developing a treatment plan and determining the level of risk to the client or others.
B. While knowing when the voices are most disturbing provides useful information for managing symptoms, it is less critical than understanding the content of the hallucinations for developing an initial treatment plan.
C. Assessing how the client copes with the voices is important for ongoing management but comes after understanding what the voices are saying. Coping strategies can be developed based on the nature of the hallucinations.
D. Determining which medication works best is not an immediate priority during the initial assessment. Medication effectiveness will be evaluated over time rather than being a primary focus during the first report of hallucinations.

A. A same-sex partner who broke her arm during a volleyball game. B. A 3-year-old with multiple old fractures of the arms and torso. C. A married man with multiple bruises to his hands and face. D. A homeless man whose clothing is soiled and has a foul-smelling body odor. E. An older adult with a skull fracture that occurred in an automobile collision.

Correct Answer is ["B","C"]

Explanation

A. A broken arm from a volleyball game is an injury that is not necessarily indicative of family violence; it appears to be an accident.
B. Multiple old fractures in a young child may indicate possible abuse or family violence, as this pattern is concerning for potential neglect or physical harm.
C. Multiple bruises on the hands and face of a married man may suggest a pattern of domestic violence, which should be reported for further assessment.
D. Soiled clothing and foul body odor may indicate poor living conditions but are not specific indicators of family violence.
E. A skull fracture from an automobile collision is likely an accident, not necessarily indicative of family violence unless further evidence suggests abuse.

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Exhibits Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with schizophrenia reports auditory hallucinations when admitted to the hospital. Which question is most important for the practical nurse (PN) to include in the assessment of this client?

Correct Answer is A

Explanation

The practical nurse (PN) is assisting with data collection for clients who have been admitted to the emergency department. What clients should the PN report to the nurse for further intervention for possible family violence? Select all that apply.

Correct Answer is ["B","C"]

Explanation

Exhibits Following the infusion of sodium chloride, the practical nurse (PN) does a focused assessment and documents the findings. Which three of the following client findings indicate that the client may still have a fluid volume deficit?

The practical nurse (PN) is reviewing home care instructions with the mother of a young girl with a urinary tract infection (UTI). Which information reported by the mother demonstrates understanding of home care for the child?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the practical nurse (PN) should take to address that condition, and two parameters the PN should monitor to assess the client's progress.

The practical nurse (PN) is assisting the recreational director of a long-term care facility plan outdoor activities for the wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?

Exhibits Review H and P and nurse's note. Which are the first four actions that the practical nurse (PN) should do?

Exhibits The practical nurse (PN) performs a focused assessment and documents it in the computer. Select what items require immediate follow-up by the PN. Select all that apply.

Exhibits Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies. What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.

Exhibits

Click to mark whether the following are signs and symptoms of cerebral edema, respiratory distress, or both.