Nursing Elites

1. After a lumbar puncture, a client reports a severe headache. What is the nurse's priority intervention?

• A. Administer a dose of acetaminophen.
• B. Elevate the head of the bed.
• C. Encourage the client to rest in a dark room.
• D. Administer caffeine to relieve the headache.

Correct answer: B

Rationale: After a lumbar puncture, a severe headache is often caused by cerebrospinal fluid leakage. Elevating the head of the bed or having the client lie flat can reduce cerebrospinal fluid pressure and alleviate the headache. These positions help prevent further fluid loss and relieve discomfort. While acetaminophen or caffeine may help in relieving the headache, changing the client's position is the priority to address the underlying cause. Resting in a dark room may be beneficial for headache relief but is not the priority intervention compared to adjusting the position to manage cerebrospinal fluid pressure.

2. The nurse is caring for a client with a traumatic brain injury who is receiving mechanical ventilation. Which assessment finding indicates that the client may be experiencing increased intracranial pressure (ICP)?

• A. Client becomes increasingly lethargic
• B. Client's respiratory rate is 16 breaths per minute
• C. Client responds to verbal stimuli
• D. Client's pupils are equal and reactive

Correct answer: A

Rationale: Increased lethargy is a sign of worsening intracranial pressure, which can be life-threatening in clients with brain injuries. As ICP rises, it can lead to decreased level of consciousness, such as lethargy or even coma. Choices B, C, and D are not indicative of increased ICP. A normal respiratory rate, response to verbal stimuli, and equal reactive pupils do not specifically point towards increased intracranial pressure.

3. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?

• A. What drugs the client used in the suicide attempt.
• B. When the client last took medications for bipolar disorder.
• C. Whether the client has attempted suicide before.
• D. Which family member has the suicide note.

Correct answer: A

Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.

4. A client is admitted to the emergency department after a motor vehicle accident. The client has a Glasgow Coma Scale (GCS) score of 10. What does this score indicate?

• A. Mild impairment
• B. Moderate impairment
• C. Severe impairment
• D. Normal

Correct answer: B

Rationale: A Glasgow Coma Scale score of 10 falls into the range of moderate impairment, indicating the need for further assessment and monitoring. A GCS score of 10 suggests that the client is moderately impaired neurologically. Choices A, C, and D are incorrect because a GCS score of 10 does not indicate mild impairment, severe impairment, or normal neurological status, respectively.

5. A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?

• A. Until the healthcare provider has determined that your ejaculate doesn't contain sperm, continue to use another form of contraception.
• B. This procedure doesn't impede the production of male hormones or the production of sperm in the testicles. The sperm can no longer enter your semen, and no sperm are in your ejaculate.
• C. After your vasectomy, strenuous activity needs to be avoided for at least 48 hours. If your work doesn't involve hard physical labor, you can return to your job as soon as you feel up to it. The stitches generally dissolve in seven to ten days.
• D. The healthcare provider at this clinic recommends rest, ice, an athletic supporter, or over-the-counter pain medication to relieve any discomfort.

Correct answer: A

Rationale: The most important point to reinforce after a vasectomy is to continue using contraception until the healthcare provider confirms the absence of sperm in the ejaculate. Choice A is correct because it emphasizes the necessity of another form of contraception until sperm absence is confirmed. Choice B is incorrect because it focuses on how a vasectomy works anatomically rather than the need for ongoing contraception. Choice C is incorrect as it discusses post-vasectomy care but does not address the need for continued contraception. Choice D is also incorrect as it refers to general post-procedure recommendations but does not highlight the crucial aspect of using contraception until sperm absence is confirmed.

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