Neuro
A nurse is caring for a client who sustained a severe traumatic brain injury and has an intraventricular catheter (ventriculostomy) placed for intracranial pressure (ICP) monitoring. Which of the following findings indicates that the client is experiencing Cushing's triad?
Correct Answer: B
A nurse is caring for a client admitted with acute decompensated left-sided heart failure. Which of the following assessment findings requires the most immediate nursing intervention?
C) Frothy, pink-tinged sputum with bilateral crackles
A nurse is reviewing telephone messages in an outpatient mental health clinic. Which of the following clients should the nurse return the call to first?
Correct Answer: C
Rationale: A rash or blisters while taking lamotrigine can indicate Stevens-Johnson syndrome (SJS), a rare, life-threatening hypersensitivity reaction that requires immediate medical intervention. Decreased libido (A), dry mouth/constipation (B), and insomnia/appetite loss (D) are expected, non-urgent side effects of those respective medications.
A nurse is performing an assessment on an infant who is diagnosed with pyloric stenosis. Which of the following clinical findings should the nurse expect?
Correct Answer: B
Rationale: Pyloric stenosis is a narrowing of the pyloric sphincter, which prevents gastric contents from entering the small intestine. This blockage results in classic projectile vomiting shortly after eating, and a palpable olive-shaped mass in the right upper quadrant. Currant-jelly stools (C) are a hallmark sign of intussusception.
A nurse is caring for a client who is 24 hours postoperative following a total hip arthroplasty. Which of the following laboratory findings should the nurse report to the provider immediately?
Correct Answer: C
Rationale: A potassium level of 2.8 mEq/L indicates severe hypokalemia, which puts the client at risk for life-threatening cardiac dysrhythmias. This requires immediate notification and replacement therapy. A slight drop in hemoglobin (A) and a mild elevation in WBCs (B) are common stress responses post-surgery. Platelets (D) are within normal limits.
A nurse in the emergency department is assessing a client who arrives within 45 minutes of experiencing acute ischemic stroke symptoms. Which of the following assessment findings represents an absolute contraindication to the administration of intravenous recombinant tissue plasminogen activator (rt-PA)?
Correct Answer: D
A) Dependent sacral and pedal edema
A nurse is providing discharge teaching to a client who has a new prescription for lithium carbonate to treat bipolar disorder. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: Lithium is a salt, and its excretion is closely tied to sodium levels. Decreasing sodium intake or becoming dehydrated causes the kidneys to reabsorb lithium, risking lithium toxicity. Fluid intake should remain around 2 to 3 L/day. NSAIDs like ibuprofen (C) increase lithium levels and should be avoided. Medications should never be stopped abruptly (D).
A nurse is caring for an infant who has a prescription for digoxin to treat congestive heart failure. Prior to administering the medication, the nurse notes the infant’s apical pulse is 82 beats per minute. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: For an infant, digoxin should be held if the apical pulse is below 90 beats per minute (for older children, typically held if below 70/min). A heart rate of 82 indicates potential digoxin toxicity or bradycardia, requiring the nurse to withhold the medication and contact the provider immediately.
A nurse is assessing a client who has a chest tube connected to a water-seal drainage system. The nurse notes continuous bubbling in the water-seal chamber. Which of the following actions should the nurse take?
Correct Answer: C
Rationale: Continuous bubbling in the water-seal chamber indicates a system air leak, which requires the nurse to check all connections from the insertion site down to the drainage unit. Intermittent bubbling is normal with coughing or expiration, but continuous bubbling is abnormal. Clamping a tube permanently (B) can cause a tension pneumothorax.
A client is admitted following an acute cervical spinal cord injury and presents with flaccid paralysis, loss of reflexes below the injury level, and bradycardia. The nurse recognizes that the client is experiencing which of the following conditions?
Correct Answer: B
A client is newly diagnosed with chronic atrial fibrillation with a rapid ventricular response (RVR). The nurse recognizes that this client is at highest risk for which of the following long-term or acute complications?
C) Thromboembolic stroke
A nurse is caring for a client who is taking haloperidol. The nurse notes that the client is experiencing severe tongue protrusion, neck twisting, and upward deviation of the eyes. Which of the following medications should the nurse prepare to administer?
Correct Answer: A
Rationale: The client is exhibiting signs of an acute dystonic reaction, a severe extrapyramidal side effect (EPS) of first-generation antipsychotics. Anticholinergic medications, such as intramuscular or intravenous benztropine or diphenhydramine, provide rapid relief. Lorazepam (B) is a benzodiazepine, propranolol (C) treats akathisia, and dantrolene (D) treats neuroleptic malignant syndrome.
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following developmental milestones should the nurse expect the infant to have achieved?
Correct Answer: B
Rationale: Rolling completely over from back to stomach (and vice versa) is an expected gross motor milestone for a 6-month-old infant. "Cruising" or walking while holding onto furniture (A) occurs closer to 11–12 months. Saying words with meaning (C) and building two-block towers (D) are milestones expected around 12 months.
A nurse is preparing to administer blood to a client. Which of the following actions must the nurse take to ensure proper client safety?
Correct Answer: A
Rationale: Blood products must always be verified by two qualified licensed professionals (usually two RNs) at the bedside before administration. Blood must be infused within a maximum of 4 hours to prevent bacterial growth (B). It must be run with 0.9% normal saline, never dextrose (C). Vital signs are typically checked before starting, 15 minutes into the infusion, and at the end (D).
A nurse is monitoring a client undergoing video EEG monitoring who experiences a generalized tonic-clonic seizure. Which of the following actions is the highest priority for the nurse during the ictal phase?
Correct Answer: B
A nurse is caring for a client following open-heart surgery who suddenly develops muffled heart sounds, hypotension, and jugular venous distension (Beck's triad). Which condition does the nurse immediately suspect?
A) Cardiac tamponade
B) Acute anterior wall myocardial infarction
C) Left ventricular wall rupture with aneurysm
A nurse is conducting an initial client interview in an outpatient clinic. Which action is the priority?
Correct Answer: B
Rationale: Assessment is the first step, allowing the nurse to understand insight and baseline coping before planning interventions.
A nurse on the labor and delivery unit is caring for a client who is at 39 weeks of gestation and receiving an oxytocin infusion. The nurse notes a pattern of late decelerations on the fetal heart rate monitor. Which of the following actions should the nurse take first?
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency and are non-reassuring. The immediate priority action is to turn the client to their side (lateral position) to relieve pressure on the vena cava and optimize placental perfusion. The oxytocin infusion must be stopped, not increased (A). Oxygen should be given via a non-rebreather mask at 8 to 10 L/min, not a nasal cannula (C).
A nurse is preparing to administer an intramuscular (IM) injection to an adult client who weighs 140 lbs. Which of the following sites is the preferred, safest choice for a deep IM injection?
Correct Answer: B
Rationale: The ventrogluteal site is the preferred and safest injection site for adults because it contains a thick muscle mass, lacks major nerves and blood vessels, and has a lower fat content than the dorsogluteal site (which is no longer recommended due to proximity to the sciatic nerve).
A nurse is assessing a client who sustained a basilar skull fracture following a motor vehicle collision. Which of the following clinical manifestations should the nurse expect to find during the focused neurological and physical assessment?
Correct Answer: C
A client returns to the unit following a left heart catheterization performed via the right femoral artery. Which of the following nursing interventions is appropriate for immediate post-procedure safety?
A) Encourage the client to ambulate to the bathroom 1 hour post-procedure
B) Maintain the client in a flat supine position with the affected right leg completely straight
C) Apply a warm moist heating pad to the right groin puncture site every 30 minutes
B) Maintain the client in a flat supine position with the affected right leg completely straight
Explanation: Correct! Keeping the affected extremity straight and the client flat/supine prevents disruption of the femoral artery closure site or bleeding/hematoma formation.
A client is actively destroying a television and yelling. What is the nurse's first action?
Correct Answer: B
Rationale: Environmental safety and securing backup are the immediate priorities.
A nurse is caring for a client at 34 weeks of gestation who presents with sudden, severe abdominal pain, uterine tenderness, and dark red vaginal bleeding. Which of the following conditions should the nurse suspect?
Correct Answer: B
Rationale: Abruptio placentae (premature separation of the placenta) is characterized by painful, dark red vaginal bleeding, uterine rigidity, and severe abdominal pain. In contrast, placenta previa (A) presents with painless, bright red vaginal bleeding. An ectopic pregnancy (C) presents in the first trimester, not at 34 weeks.
A nurse is performing a physical assessment on a client with a history of severe chronic obstructive pulmonary disease (COPD). Which of the following structural findings should the nurse expect?
Correct Answer: B
Rationale: Long-standing air trapping in COPD causes hyperinflation of the lungs, leading to a barrel chest, which is characterized by an increased AP chest diameter (equal 1:1 ratio instead of the normal 1:2 ratio). Asymmetrical chest expansion (C) points to conditions like a pneumothorax or atelectasis.