the nurse is caring for a client with increased intracranial pressure icp which position should the nurse avoid
Logo

Nursing Elites

HESI LPN

Adult Health 1 Exam 1

1. The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?

Correct answer: B

Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.

2. A healthcare provider is reviewing a client's medication list during a routine visit. Which action is most important to ensure medication safety?

Correct answer: D

Rationale: A comprehensive review of allergies, medication purposes, and potential interactions is crucial for ensuring medication safety. Asking about allergies helps prevent adverse reactions, reviewing medication purposes ensures the correct use of each drug, and checking for potential drug interactions reduces the risk of harmful effects when medications interact. Choosing 'All of the above' is the correct answer because all three actions are essential steps to enhance medication safety. Options A, B, and C individually play vital roles in promoting medication safety, making option D the most appropriate choice.

3. When assisting a client to obtain a sputum specimen, the nurse observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next?

Correct answer: C

Rationale: After observing the client cough and produce frothy saliva in the collection cup, the nurse should provide the client with a glass of water and mouthwash to rinse the mouth. This action helps clear the mouth of contaminants, ensuring a more accurate sputum specimen for diagnostic testing. Option A is incorrect because suctioning is not the appropriate next step in this situation. Option B is unnecessary as re-instructing the client in coughing techniques may not address the immediate issue of contaminated saliva in the specimen. Option D is premature since labeling and transporting the container should only be done after obtaining a valid specimen.

4. What is the function of the cervix in reproduction?

Correct answer: B

Rationale: The cervix functions in reproduction by secreting mucus that facilitates the transport of sperm to the uterus. Choice A is incorrect because the cervix does not interpret signals of sexual stimuli. Choice C is incorrect as the site for the union of ovum and sperm is the fallopian tube. Choice D is incorrect as the cervix is not involved in receiving the penis during intercourse.

5. The nurse is caring for a client with a diagnosis of major depressive disorder who has been prescribed a selective serotonin reuptake inhibitor (SSRI). What is the most important teaching point?

Correct answer: D

Rationale: The correct answer is D: 'Report any thoughts of self-harm immediately.' Clients prescribed SSRIs should be educated to report any thoughts of self-harm promptly, as these medications can initially increase suicidal ideation. Choice A is incorrect because SSRIs are usually taken on an empty stomach. Choice B is incorrect as it takes several weeks for SSRIs to reach their full effectiveness. Choice C is irrelevant to SSRI therapy.

Similar Questions

When teaching a diabetic client about foot care, what information is most important?
A client with a history of peptic ulcer disease (PUD) is prescribed omeprazole (Prilosec). What is the primary action of this medication?
A client with a history of pulmonary embolism is on anticoagulant therapy. What should the nurse monitor regularly?
What should the nurse prioritize when providing discharge instructions to a client with a new colostomy?
A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the nurse provide?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses