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Questions 149

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Question 1 of 5

A nurse is observing a local softball game when one of the players is hit in the nose with a ball. The player's nose is visibly deformed and bleeding. The best way for the nurse to control the bleeding is to:

Correct Answer: D

Rationale: Tilting the head forward and pinching the nostrils prevents blood from entering the airway and controls bleeding.

Question 2 of 5

The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:

Correct Answer: A

Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.

Question 3 of 5

A client with schizophrenia is started on Zyprexa (olanzapine). Three weeks later, the client develops severe muscle rigidity and elevated temperature. The nurse should give priority to:

Correct Answer: D

Rationale: Severe muscle rigidity and fever suggest neuroleptic malignant syndrome (NMS), a medical emergency requiring immediate transfer to a medical unit for treatment.

Question 4 of 5

Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?

Correct Answer: A

Rationale: Chemotherapy suppresses the immune system, increasing the risk of opportunistic infections like pneumocystis pneumonia.

Question 5 of 5

The physician has ordered an infusion of Osmitrol (mannitol) for a client with increased intracranial pressure. Which finding indicates the direct effectiveness of the drug?

Correct Answer: B

Rationale: Mannitol is an osmotic diuretic that reduces intracranial pressure by increasing urinary output, drawing fluid out of the brain tissue.

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