Patient Data

Exhibits

Review H and P, nurse's note, flow sheet, and prescriptions.

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

Answer and Explanation

The Correct Answer is []

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

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Correct Answer is D

Explanation

A. The adult nurse practitioner may be involved in direct patient care but is not typically responsible for coordinating the overall progression of care.

B. The neurology unit supervisor might oversee the neurology-related aspects but not the overall case management.

C. The risk management nurse deals with issues related to patient safety and quality but does not usually coordinate patient care.

D. The nurse case manager is specifically responsible for coordinating the progression of care, including planning, implementing, and evaluating the overall treatment plan.

A. Note the presence of an auscultatory gap. B. Reposition the stethoscope over the brachial artery. C. Continue with the blood pressure assessment. D. Reinflate the cuff to a higher number.

Correct Answer is C

Explanation

A. While the nurse should be aware of the gap, they must first complete the assessment rather than stopping at this point.

B. Repositioning the stethoscope is not necessary if the sounds are heard clearly.

C. Thenurse should not stop or make assumptions but should continue listening to detect the reappearance of Korotkoff sounds and obtain an accurate diastolic reading.

D. Re-inflating the cuff to a higher number is unnecessary unless the initial reading was unclear or the cuff was under-inflated.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is admitted to the intensive care until (ICU) with a spinal cord injury following a motor vehicle collision. Which nurse should be contacted to coordinate the progression of the client's care?

Correct Answer is D

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is C

Explanation

The nurse is providing education to a client who receives a prescription for zolpidem. Which information about the medication should the nurse include?

A client with advanced cirrhosis is being treated for hepatic encephalopathy. In reviewing the client's serum laboratory results, which finding requires the most immediate intervention by the nurse?

What statement by a client who is 24 hours post-subtotal thyroidectomy requires an immediate investigation by the nurse?

A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). On examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated blood pressure. Which intervention should the nurse implement first?

While preparing a client's routine 0800 medications, the nurse opens the medication packaging and discards in the trash prior to scanning the barcode label. Which action should the nurse implement?

Patient Data Exhibits Which are the 3 most important goals that would help the nurse evaluate the treatment of this client at discharge?

When planning care for a client with acute pancreatitis, which nursing intervention has the highest priority?