a nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury tbi what finding should the nurse recogni
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Nursing Elites

ATI LPN

PN ATI Capstone Pharmacology 1 Quiz

1. A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?

Correct answer: D

Rationale: Unequal pupils are a sign of increased intracranial pressure or worsening brain injury, indicating a serious complication that requires immediate medical attention. Hypertension, vomiting, and drainage from the ear are not typically associated with minor traumatic brain injury complications; therefore, they are not the priority findings to report to the provider.

2. A healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?

Correct answer: B

Rationale: For clients with dementia who have difficulty communicating, assessing pain using behavioral indicators like increased agitation and restlessness is more effective than relying on self-reported scales such as numeric rating scale, visual analog scale, or faces pain scale. Behavioral indicators provide valuable insights into pain perception in individuals who may have challenges expressing themselves verbally.

3. A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?

Correct answer: D

Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.

4. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

5. A nurse is teaching the parents of a newborn how to care for their child's uncircumcised penis. Which of the following instructions should the nurse include?

Correct answer: D

Rationale: The correct answer is to wash the penis once a day with soap and water. It is important to advise against forcefully retracting the foreskin as it can cause pain and injury. Using a cotton swab is not recommended as it can introduce foreign particles, and applying petroleum jelly is unnecessary and may lead to issues. Washing with soap and water is sufficient for hygiene without the need for additional products or manipulation of the foreskin.

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