During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?

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Question 1 of 5

During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?

Correct Answer: A

Rationale: The modified Trendelenburg position involves placing the client with their legs elevated higher than their head. This position promotes venous return to the heart, increasing preload and cardiac output, thereby leading to an increase in blood pressure. Elevating the legs helps to reduce peripheral edema and improve circulation. Therefore, the correct answer is A. Choice B is incorrect because the Trendelenburg position does not directly affect the respiratory rate. Choice C is incorrect as the position is not intended to increase heart rate but rather improve venous return. Choice D is also incorrect as the primary goal of the Trendelenburg position is not to decrease blood loss, although it may help in some cases by improving circulation.

Question 2 of 5

Mr. Reyes has a possible skull fracture. The nurse should:

Correct Answer: A

Rationale: The correct answer is A because signs of brain injury, such as altered level of consciousness, unequal pupil size, and clear fluid draining from the nose or ears, indicate a need for urgent medical attention. Choice B is incorrect because hemorrhaging from the oral cavity is not a common sign of a skull fracture. Choice C is incorrect as elevating the foot of the bed is not appropriate for a skull fracture but may be done for shock. Choice D is incorrect because decreased intracranial pressure and temperature are not typical symptoms of a skull fracture.

Question 3 of 5

Considering Mr. Franco’s conditions, which of the following is most important to include in preparing Franco’s bedside equipment?

Correct Answer: C

Rationale: Step 1: Mr. Franco's condition suggests he may need support and positioning. Step 2: Sandbags provide stability and trochanter rolls prevent hip rotation. Step 3: These help prevent pressure ulcers and maintain proper body alignment. Step 4: Hand bell and bed linen are not essential for Mr. Franco's immediate care. Step 5: Footboard and splint may not be relevant to his specific condition. Step 6: Suction machine and gloves are important but not as crucial as positioning aids for Mr. Franco. Summary: Choice C is correct as it directly addresses Mr. Franco's needs for support and positioning, while the other choices are less relevant or not as essential in this context.

Question 4 of 5

A male client, age 45, undergoes a lumbar puncture in which CSF was extracted for a particular neurologic diagnostic procedure. After the procedure, he complains of dizziness and a slight headache. Which of the ff steps must the nurse take to provide comfort to the client? Choose all that apply

Correct Answer: A

Rationale: The correct answer is A: Position the client flat for at least 3 hrs or as directed by the physician. Rationale: 1. Positioning the client flat helps prevent post-lumbar puncture headache by allowing the CSF to replenish and stabilize the pressure in the spinal canal. 2. The recommended time frame of 3 hours allows for adequate CSF reabsorption and reduces the likelihood of headache. 3. Following physician's direction is crucial to individualize care based on the specific situation. Summary of other choices: B: Encouraging fluid intake is generally good practice but may not directly alleviate post-lumbar puncture headache. C: Keeping the room well lit and playing soothing music may not address the physiological cause of the client's symptoms. D: Ambulation and leg exercises are not recommended immediately post-lumbar puncture as they may exacerbate dizziness and headache.

Question 5 of 5

Which of the ff is the characteristic of a ketogenic diet that is suggested for children with seizures?

Correct Answer: B

Rationale: Correct Answer: B (High fat diet) Rationale: 1. Ketogenic diet for seizures aims to produce ketones for brain energy, achieved through high fat intake. 2. High fat intake helps induce ketosis, which may help reduce seizures in some children. Incorrect Choices: A: High carbohydrate diet - Contradicts the purpose of a ketogenic diet. C: High protein diet - Excessive protein can hinder ketosis and is not the primary focus of a ketogenic diet. D: Low fat diet - Opposite of the high fat requirement for a ketogenic diet to induce ketosis.

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