Nursing Elites

1. A young adult was hit in the temporal area with a baseball bat and is being monitored for signs of a closed head injury. Which finding indicates a developing epidural hematoma?

• A. Nausea and vomiting.
• B. Altered consciousness within the first 24 hours after injury.
• C. Severe headache and blurred vision.
• D. Loss of motor function on the affected side.

Correct answer: B

Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.

2. A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?

• A. Have him drink several glasses of water
• B. Crede the bladder from the bottom to the top
• C. Assist him to stand by the side of the bed to void
• D. Wait 2 hours and have him try to void again

Correct answer: C

Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action in this situation. Standing to void often helps relieve the bladder, especially after surgery. Option A, having him drink several glasses of water, may not be as effective as the client might already be adequately hydrated. Option B, Crede maneuver, is a technique for emptying the bladder by applying manual pressure and is not the first-line intervention for a client who cannot void post-surgery. Option D, waiting 2 hours before trying to void again, may delay necessary intervention if the client is experiencing urinary retention.

3. A client is admitted with a suspected pulmonary embolism (PE). What is the nurse's priority intervention?

• A. Administer anticoagulant therapy as prescribed.
• B. Elevate the head of the bed to 45 degrees.
• C. Check the client's oxygen saturation.
• D. Prepare the client for a CT scan.

Correct answer: D

Rationale: The correct answer is to prepare the client for a CT scan. A CT scan is essential in confirming the presence of a pulmonary embolism (PE) and guiding further treatment. Administering anticoagulant therapy (Choice A) is important in the management of PE, but it is not the priority intervention in this case. Elevating the head of the bed (Choice B) is beneficial for optimizing oxygenation but is not the priority intervention when a PE is suspected. Checking the client's oxygen saturation (Choice C) is important, but obtaining a definitive diagnosis through a CT scan takes precedence in this situation.

4. A client with a history of adrenal insufficiency is admitted with acute adrenal crisis. The client complains of nausea and joint pain, vital signs show a temperature of 102°F, heart rate of 138, and blood pressure of 80/60. Which intervention should the nurse implement first?

• A. Obtain an analgesic prescription.
• B. Infuse an intravenous fluid bolus.
• C. Administer PRN oral antipyretic.
• D. Cover the client with a cooling blanket.

Correct answer: B

Rationale: In acute adrenal crisis, the priority intervention is to infuse an intravenous fluid bolus to address the hypotension (blood pressure of 80/60) and help stabilize the client's condition. Adequate fluid volume is crucial in managing adrenal insufficiency crisis. Options A, C, and D do not directly address the hypotension and fluid volume depletion that are critical in this situation. Analgesics, antipyretics, and cooling blankets may be considered later, but the immediate focus should be on fluid resuscitation.

5. The nurse is caring for a client with deep vein thrombosis (DVT) who is receiving anticoagulant therapy. Which intervention should the nurse implement to prevent complications?

• A. Elevate the affected leg
• B. Encourage early ambulation
• C. Perform frequent range-of-motion exercises
• D. Apply ice packs to the affected leg

Correct answer: A

Rationale: Elevating the affected leg is crucial in managing deep vein thrombosis (DVT) as it helps to reduce swelling and improve venous return. This intervention is essential for preventing complications such as pulmonary embolism. Encouraging early ambulation is generally beneficial for preventing DVT but is secondary to leg elevation. Performing range-of-motion exercises can be helpful for maintaining joint mobility but is not the priority intervention in this case. Applying ice packs to the affected leg is not recommended in DVT management as it can cause vasoconstriction and potentially worsen the condition.

Similar Questions