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. During an initial assessment, a healthcare provider notes that a client has elevated blood pressure. Which of the following findings is considered a major risk factor for coronary artery disease?

• A. Elevated HDL cholesterol
• B. Low LDL cholesterol
• C. Elevated blood pressure
• D. Low triglyceride levels

Correct answer: C

Rationale: Elevated blood pressure is a significant risk factor for coronary artery disease because it increases the strain on the arteries, leading to potential damage and a higher risk of developing coronary artery disease. Elevated HDL cholesterol (Choice A) is actually considered beneficial as it helps reduce the risk of heart disease. Low LDL cholesterol (Choice B) is also beneficial as high levels of LDL are associated with an increased risk of coronary artery disease. Low triglyceride levels (Choice D) are not typically considered a major risk factor for coronary artery disease.

3. A client with deep vein thrombosis (DVT) is prescribed warfarin. What teaching should the nurse provide to the client?

• A. Avoid leafy green vegetables while taking warfarin.
• B. Report any unusual bruising or bleeding.
• C. Take warfarin at the same time every day.
• D. Avoid alcohol consumption while on warfarin.

Correct answer: D

Rationale: The correct answer is D: 'Avoid alcohol consumption while on warfarin.' Alcohol can increase the risk of bleeding when taken with warfarin, so it should be avoided. Choice A is incorrect as leafy green vegetables contain vitamin K, which can interfere with the anticoagulant effects of warfarin. Choice B is important but not directly related to alcohol consumption. Choice C is a general instruction for medication adherence but not specifically related to the interaction with alcohol.

4. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

• A. Decreased heart rate
• B. Increased appetite
• C. Cold intolerance
• D. Weight gain

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

5. Following a cardiac catheterization and placement of a stent in the right coronary artery, the nurse administers prasugrel, a platelet inhibitor, to the client. To monitor for adverse effects from the medication, which assessment is most important for the nurse to include in this client's care plan?

• A. Check platelet count
• B. Observe the color of urine
• C. Review liver function tests
• D. Monitor for bleeding

Correct answer: D

Rationale: Prasugrel is a platelet inhibitor, which increases the risk of bleeding. Monitoring for bleeding, particularly at the catheterization site and in other areas, is the most important assessment following administration of the drug. Checking platelet count and observing urine color are relevant but not as immediate. Reviewing liver function tests is not directly related to the adverse effects of prasugrel.

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