1. A nurse is caring for a client who had a cerebrovascular accident 2 days ago.
Which of the following is the first sign of increased intracranial pressure (ICP)?
A. Pupil dilation
B. Ataxia
C. Lethargy
D. Bradycardia Ans: C. Lethargy
*The content of this question emphasizes the concept of safety through the iden- tification
of an initial manifestation of increased ICP. Safety in nursing practice is the minimization
of risk factors that can cause injury or harm while promoting quality care and maintaining
a secure environment for clients, self, and others.
By recognizing and anticipating potential complications, nurses are better able to predict
a needed intervention, which assists in preventing or minimizing physical or
psychological harm to the client. Lethargy occurs when pressure is placed on the
reticular activating system within the brainstem. Along with other indicators of a change
in the level of consciousness, such as restlessness, irritability, and disorientation,
lethargy is the first sign of increased ICP.
2. A nurse at a long-term care facility is participating in a quality improvement
project to reduce the occurrence of pressure ulcers. Which of the following audits
,should be conducted to determine the impact of a new skincare regi- men on the
incidence of pressure ulcers among clients who are immobile?
A. Prospective audit
B. Outcome audit
C. Process audit
D. Structure audit Ans: B. Outcome Audit
*The content of this question emphasizes the concept of quality improvement by
selecting the appropriate audit to conduct when determining the impact of a
new skincare regimen on the incidence of pressure ulcers among clients who are immobile
The primary goal of quality improvement is developing and implementing a plan to
improve health care services and better meet the needs of clients. To accomplish this goal it
is necessary to recognize client and facility issues that impact the provision of safe, quality
care, as well as identify gaps between current practices and best practices. Audits are a
process of measuring the quality of delivered care so better practices can be developed and
implemented when needed. An outcome audit is conducted to determine the actual result a
specific nursing intervention has had on client outcomes. This type of audit is appropriate
to use when determining the impact of a new skincare regimen on the incidence of
pressure ulcers among clients who are immobile.
, 3. A nurse is reinforcing teaching about client consent to treatment with a group of
newly licensed nurses. Which of the following statements by a newly licensed nurse
indicates a need for further teaching?
A. "It is necessary to have written consent for invasive procedures."
B. "Implied consent is appropriate for some aspects of nursing care."
C. "It is the responsibility of the provider to obtain express consent."
D. "Informed consent should be obtained separately for each surgical proce- dure."
Ans: C. "It is the responsibility of the provider to obtain express consent."
*The content of this question emphasizes the concept of professionalism by en- suring
understanding of the legal concept of consent. Professionalism incorporates legal and
ethical principles, as well as compliance with the standards of nursing practice in the
provision of safe, quality nursing care that exhibits both accountable and responsible
behaviors. Nurses frequently obtain express consent by witnessing a client sign a consent
form after ensuring the client has received and understands necessary information regarding
the procedure.This is not an appropriate statement by a newly licensed nurse and requires
further teaching.
4. A nurse is caring for a child who has leukemia and is prescribed a trans- fusion
of platelets. Which of the following should the client experience as a result of the
transfusion?