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Question 1 of 5

The nurse caring for a client with a head injury would recognize which assessment finding as the most indicative of increased ICP?

Correct Answer: D

Rationale: Papilledema (optic disc swelling) is a specific sign of increased ICP due to pressure on the optic nerve. Nausea, headache, and dizziness are less specific.

Question 2 of 5

The nurse identifies ventricular tachycardia on the heart monitor. The nurse should immediately:

Correct Answer: C

Rationale: Ventricular tachycardia requires immediate treatment with an antiarrhythmic like lidocaine to restore normal rhythm.

Question 3 of 5

The nurse is caring for a 10-year-old boy with hemophilia. The nurse suspects the child has developed hemarthrosis when she observes

Correct Answer: D

Rationale: Hemarthrosis (joint bleeding) in hemophilia presents with redness, swelling, and warmth over the joint due to blood accumulation.

Question 4 of 5

A 2-year-old is hospitalized with a diagnosis of Kawasaki's disease. A severe complication of Kawasaki's disease is:

Correct Answer: D

Rationale: Kawasaki's disease can lead to coronary artery aneurysms, a severe complication that may cause myocardial infarction or rupture.

Question 5 of 5

The nurse is caring for a client with suspected meningitis who will be having a lumbar puncture. Which statement regarding aftercare is correct?

Correct Answer: D

Rationale: Post-lumbar puncture care includes assessing for neurological changes, pain, drainage, and voiding to detect complications like nerve injury or CSF leak.

Similar Questions

Upon arrival in the nursery, erythomycin eyedrops are applied to the newborn's eyes. The nurse understands that the medication will:
What airborne precautions should the nurse anticipate when a client with measles is admitted to the hospital? Select all that apply.
The nurse is caring for a client in intensive care with a diagnosis of traumatic brain injury. The client is found to be restless, complains of extreme nausea, and is weak on the left arm and leg. Which is the best response by the nurse?
The nurse caring for clients with coronary artery disease recognizes which one of the following as a modifiable risk factor?
The nurse is teaching the client regarding use of sodium warfarin. Which statement made by the client would require further teaching?

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