Update) Transition to Practice-Capstone |
Questions and Verified Answers | 100% Correct |
Graded A+ – Fortis
QUESTION
The nurse is caring for a client receiving an albuterol/ipratropium nebulized
breathing treatment. Which report from the client should the nurse note as an
expected side effect of this combination?
Answer:
I feel like my heart is racing.
QUESTION
The nurse is monitoring a 3-year-old child for signs and symptoms of increased
intracranial pressure
(ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom
of increased ICP?
Answer:
Vomiting
QUESTION
A mother arrives at the emergency department with her 5-year-old chills and states
that the child fell off a
bunk bed. A head injury is suspected. The nurse checks the child's airway status
and assesses the child for early and late signs of ICP.Which is the late sign?
Answer:
,Bradycardia
QUESTION
The nurse is reviewing the record of a child with ICP and notes that the child
has exhibited signs of decerebrate posturing. On assessment of the child, the
nurse expects to note which characteristic of this type posturing?
Answer:
Rigid extension and pronation of the arms and legs
QUESTION
The nurse is assessing the motor and sensory function of an unconscious client
who sustained a head injury. The nurse should use which technique to test the
client's peripheral response to pain?
Answer:
Nail Bed pressure
QUESTION
The nurse is caring for the client with ICP as a result of a head injury/ the nurse would note which
trend in VS if the intracranial pressure is rising?
Answer:
Increasing temp, decreasing pulse, decreasing respirations, increasing blood pressure
QUESTION
A child becomes cyanotic during a generalized tonic-clonic seizure. What is the
most appropriate action by the nurse?
Answer:
Continuing to observe the seizure
,QUESTION
A nurse is providing discharge teaching to parents whose infant had a
ventriculoperitoneal shunt
placement for the treatment of hydrocephalus. Which of the following statements
by the parents indicates an understanding of the teaching?
Answer:
We will notify the doctor right away if he has a fever.
QUESTION
Important to communicate to the surgeon after ventriculoperitoneal shunt is placed?
3-year-old returned ped unit
Answer:
the right pupil is 1mm larger than the left eye
QUESTION
The nurse is evaluating the status of a client who had a craniotomy 3 days ago.
Which assessment finding would indicate that the client is developing meningitis
as a complication of surgery?
Answer:
A positive Brudzinski's sign
QUESTION
The nurse notes documentation that a child is exhibiting an inability to flex leg
when the thigh is flexed anteriorly at the hip. Which condition does the nurse
suspect?
Answer:
, Meningitis
QUESTION
A lumbar puncture is performed on a child suspected to have bacterial meningitis,
and cerebrospinal fluid
is obtained for analysis. The nurse reviews the results of the CSF analysis and
determines which results
would verify the diagnosis
Answer:
Cloudy CSF, elevated protein, and decrease glucose levels
QUESTION
The nurse is assessing a client for meningeal irritation and elicits a positive
Brudzinski's sign. Which finding did the nurse observe
Answer:
The client passively flexes the hip and knee in response to neck flexion and reports
pain in the vertebral column.
QUESTION
The home health nurse is visiting a client with a diagnosis of multiple sclerosis. The
client has been
taking oxybutynin (Ditropan XL). The nurse evaluates the effectiveness of the
medication by asking the client which assessment question?
Answer:
"Are you getting up at night to urinate?"
QUESTION
The home health nurse visits a client who is taking phenytoin for control of
seizures. During the assessment, the nurse notes that the client is taking birth
control pills. Which information should the nurse include in the teaching plan?