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1. The healthcare professional is preparing to percuss the abdomen of a patient. What characteristic of the underlying tissue does percussion assess?
- A. Turgor
- B. Texture
- C. Density
- D. Consistency
Correct answer: C: Density
Rationale: Percussion is a technique used to assess the density of underlying organs by producing sounds that help determine their location and size. Turgor, texture, and consistency are primarily assessed through palpation, not percussion. Turgor refers to skin elasticity, texture pertains to the feel of the tissue surface, and consistency relates to the firmness or resistance of the tissue.
2. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?
- A. Administer hypotonic solutions
- B. Keep the head of the bed elevated
- C. Increase the client's core body temperature to 99.9 degrees
- D. Administer corticosteroids as ordered
Correct answer: Administer corticosteroids as ordered
Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.
3. Mary T. was admitted to a nursing home on May 1st. On July 4th, she was diagnosed with a skin infection. This infection is considered a ________________ infection.
- A. nosocomial
- B. systemic
- C. resident flora
- D. resident aura
Correct answer: nosocomial
Rationale: The correct answer is 'nosocomial.' A nosocomial infection is defined as one that is not present upon admission to a healthcare facility but instead occurs during the patient's stay. In this case, since Mary was diagnosed with a skin infection after being admitted to the nursing home, it is considered a nosocomial infection. Nosocomial infections are a significant concern in healthcare settings, and infection control measures are in place to prevent their spread. Choices B, C, and D are incorrect. 'Systemic' refers to a condition affecting the entire body, not specific to a healthcare setting. 'Resident flora' and 'resident aura' are not commonly used terms in healthcare and do not relate to infections acquired in healthcare facilities.
4. A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
- A. Pulmonary embolectomy
- B. Vena caval interruption
- C. Increasing the coumadin therapy to achieve an INR of 3-4
- D. Thrombolytic therapy
Correct answer: Vena caval interruption
Rationale: In the case of a client with a history of recurrent pulmonary embolism or contraindications to heparin, vena caval interruption may be necessary. Vena caval interruption involves placing a filter device in the inferior vena cava to prevent clots from traveling to the pulmonary circulation. Pulmonary embolectomy is a surgical procedure to remove a clot from the pulmonary artery, which is usually considered in severe or life-threatening cases. Increasing coumadin therapy to achieve a higher INR may be an option but vena caval interruption would be more appropriate in this scenario. Thrombolytic therapy is used in acute cases of pulmonary embolism to dissolve the clot rapidly, but in a recurrent case with contraindications to anticoagulants, vena caval interruption would be a preferred intervention.
5. Which response would the nurse make to a client who says, 'The voices say I’ll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?
- A. Ask whether the voices are male or female and how many there are.
- B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don’t hear them.'
- C. Offer false reassurance by saying, 'Don’t worry—I’ve locked the door to your room and won’t let anyone in.'
- D. Encourage the client to leave the room and keep busy to distract from the voices.
Correct answer: Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don’t hear them.'
Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don’t hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.
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