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Question 1 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (
B), turning (
C), or supine positioning (
D) delays critical action.

Question 2 of 5

Due to his prolonged history of alcohol abuse, an alcoholic client will most likely have deficiencies of which of the following nutrients?

Correct Answer: D

Rationale: Chronic alcoholism can lead to deficiencies of B complex vitamins including thiamine and pyroxidine.

Question 3 of 5

The nurse is caring for a client with a history of a hysterectomy. The client complains of hot flashes. The nurse should:

Correct Answer: C

Rationale: Hot flashes post-hysterectomy are due to hormonal changes. Discussing hormone replacement therapy with the physician is appropriate. Heating pads, fluid restriction, and acetaminophen are ineffective.

Question 4 of 5

A 65-year-old client is admitted after a stroke. Which nursing intervention would best improve tissue perfusion to prevent skin problems?

Correct Answer: D

Rationale: Performing range-of-motion exercises and turning/repositioning enhances blood flow to tissues, reducing the risk of pressure ulcers by relieving pressure points. Assessing skin (
A) is monitoring, not an intervention to improve perfusion. Massaging erythematous areas (
B) can worsen tissue damage. Changing pads (
C) prevents irritation but doesn’t directly improve perfusion.

Question 5 of 5

A client with BPH has undergone a TURP. Which nursing interventions are parts of the client's post-operative care?

Question Image

Correct Answer: A, B, D

Rationale: Post-TURP care includes monitoring vital signs (
A), constant bladder irrigation (
B) to prevent clots, and checking for bleeding (
D). Fluid intake is encouraged (
C), and bed rest is typically 24 hours (E).

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