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 client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?

• A. Allow the client to melt ice chips in the mouth
• B. Provide mints to freshen the breath
• C. Perform frequent oral care with a tooth sponge
• D. Swab the mouth with glycerin swabs

Correct answer: C

Rationale: Performing frequent oral care with a tooth sponge is the most appropriate nursing measure in this scenario. This helps maintain comfort and prevent dryness in clients with nasogastric tubes. Allowing the client to melt ice chips in the mouth may not address oral care needs effectively. Providing mints to freshen the breath is not the priority when the client needs oral care. Swabbing the mouth with glycerin swabs may not be as effective as performing thorough oral care with a tooth sponge.

3. The nurse is preparing an older adult for discharge following cataract extraction. What is the most important instruction?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Use direct lighting when reading for 6 weeks.
• D. Irrigate the conjunctiva with saline before applying ointment.

Correct answer: A

Rationale: The most important instruction for a patient following cataract extraction is to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure and potentially lead to complications such as bleeding or dislocation of the intraocular lens. Choices B, C, and D are not as critical in the immediate post-operative period. Limiting sunlight exposure and using direct lighting when reading are important but not as crucial as avoiding activities that can increase intraocular pressure. Irrigating the conjunctiva with saline before applying ointment is not a standard post-cataract surgery instruction.

4. A client with acute pancreatitis is receiving intravenous fluids and pain medication. What is the priority assessment for this client?

• A. Monitor bowel sounds
• B. Measure urine output
• C. Assess for abdominal tenderness
• D. Monitor blood glucose levels

Correct answer: D

Rationale: The correct answer is D: Monitor blood glucose levels. Clients with acute pancreatitis are prone to hyperglycemia due to impaired insulin production. Monitoring blood glucose levels is crucial to prevent complications like diabetic ketoacidosis. While assessing bowel sounds, urine output, and abdominal tenderness are important in the overall care of a client with acute pancreatitis, monitoring blood glucose levels takes priority to address the immediate risk of hyperglycemia.

5. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide to the client?

• A. Avoid leafy green vegetables while taking warfarin.
• B. Report any unusual bruising or bleeding.
• C. Take warfarin at the same time every day.
• D. Avoid alcohol consumption while on warfarin.

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol consumption while on warfarin.' Alcohol can increase the risk of bleeding when taken with warfarin, so it should be avoided. Choice A is incorrect as leafy green vegetables contain vitamin K, which can interfere with the anticoagulant effects of warfarin. Choice B is important but not directly related to alcohol consumption. Choice C is a general instruction for medication adherence but not specifically related to the interaction with alcohol.

Similar Questions