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Question 1 of 5

A 14-year-old boy has a head injury with laceration of his scalp over his ear. The nurse should call the physician to report:

Correct Answer: D

Rationale: This change in blood pressure may not be significant and does not indicate a widening pulse pressure, a late sign of increased ICP. It is important to continue to monitor for change in blood pressure. Acetaminophen may be ineffective in relieving headache after head injury. Stronger analgesics are contraindicated because they mask neurological signs and may depress the CNS. Pulse rates between 68 bpm and 76 bpm are within normal limits for a 14-year-old child. It is important to monitor for a consistent drop in pulse rate, which is a late sign of increasing ICP. An elevated temperature is abnormal and requires further assessment and medical intervention. The temperature may be unrelated to the head injury, but CNS infection is serious and difficult to control.

Question 2 of 5

Nursing care of the infant prior to surgical closure of a meningomyelocele would include:

Correct Answer: B

Rationale: A saline-soaked sterile dressing protects the sac from contamination by air and prevents drying.

Question 3 of 5

When preparing a client for magnetic resonance imaging, the nurse should implement which of the following?

Correct Answer: C

Rationale: Removing jewelry and checking for metal implants prevents MRI-related injuries due to magnetic fields. Consent and atropine (
A), scrubbing (
B), and Benadryl (
D) are not standard for MRI prep.

Question 4 of 5

The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?

Correct Answer: B

Rationale: Pernicious anemia, caused by vitamin B12 deficiency, leads to neurological symptoms like numbness and tingling due to nerve demyelination. The other symptoms are common in various anemias.

Question 5 of 5

Which statement describes the contagious stage of varicella?

Correct Answer: D

Rationale: Varicella (chickenpox) is contagious from 1-2 days before the rash until all lesions are crusted, as the virus is shed during this period. Earlier or later stages are less contagious.

Similar Questions

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The physician orders medication for a client's unpleasant side effects from the haloperidol. The most appropriate drug at this time is:
The nurse is caring for a client with a history of Ménière’s disease. The nurse should expect the client to have:
The nurse is caring for a client post-appendectomy. Which finding requires immediate intervention?
For the past several months, an elderly female client with Alzheimer's disease has experienced paranoia; hallucinations; and aggressive, disruptive behavior. The family is utilizing haloperidol as needed to control her behavior. On nursing assessment, you note that the client demonstrates involuntary movements of the tongue and fingers. This may most likely indicate:

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