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Question 1 of 5

The unit nurse is teaching a nursing student about increased intracranial pressure (ICP). The nurse knows the teaching was effective if the student nurse makes which statement?

Correct Answer: D

Rationale: Late ICP signs include Cushing’s triad: increased systolic BP, widened pulse pressure, and bradycardia, reflecting brainstem compression.

Question 2 of 5

A client on a 72-hour psychiatric hold experiences a panic attack while getting ready for the day. The nurse should provide the following interventions ranked by priority:

Order the Items

Source Container

stay with the client until the panic attack is over
incorporate physical activity into the client's daily routine
instruct the client to take slow, deep breaths
reduce external stimuli in the immediate area
work with the client to develop coping mechanisms

Correct Answer: A,D,C,E,B

Rationale: Priority order: Stay with the client (
A) for safety, reduce stimuli (
D) to calm the environment, instruct deep breathing (
C) to manage symptoms, develop coping mechanisms (E) for future prevention, and incorporate physical activity (
B) as a long-term strategy.

Question 3 of 5

A client requires insertion of a nasogastric tube. When preparing the client for the procedure, the nurse should place the client in which of the following positions?

Correct Answer: A

Rationale: High Fowler's position with the head tilted forward (
A) facilitates nasogastric tube insertion by aligning the esophagus and reducing the risk of aspiration. Tilting the head backward (B,
D) or using a neutral position in semi-Fowler's (
C) is less effective for this procedure.

Question 4 of 5

The client arrives in the emergency department after a motor vehicle accident. Nursing assessment findings include BP 68/34, pulse rate 130, and respirations 18. Which is the client's most appropriate priority nursing diagnosis?

Correct Answer: B

Rationale: The vital signs indicate hypovolemic shock, making fluid volume deficit the priority nursing diagnosis.

Question 5 of 5

Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should

Correct Answer: C

Rationale: Compazine should be considered incompatible in a syringe with all other medications

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A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.
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