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Questions 149

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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 is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:

Correct Answer: A

Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.

Question 3 of 5

The nurse is planning dietary changes for a client following an episode of acute pancreatitis. Which diet is suitable for the client?

Correct Answer: B

Rationale: A high-calorie, low-fat diet is suitable post-acute pancreatitis to support recovery while minimizing pancreatic stimulation.

Question 4 of 5

If a nurse accidentally punctures a finger with a needle after withdrawing blood from a client, which of the following actions should be carried out first?

Correct Answer: B

Rationale: Washing the puncture with soap and water (
B) is the first step to reduce infection risk. Other actions (A, C,
D) follow.

Question 5 of 5

A client taking Dilantin (phenytoin) for tonic-clonic seizures is preparing for discharge. Which information should be included in the client's discharge care plan?

Correct Answer: C

Rationale: Phenytoin requires regular blood work to monitor levels and prevent toxicity, which can cause side effects like gingival hyperplasia.

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