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,
,The nurse is completing the admission assessment of a 3-
year old who is admitted with bacterial meningitis and
hydrocephalus. Which assessment finding is evidence that
the child is experiencing increased intracranial pressure
(ICP)?
A. Tachycardia and tachypnea
B. Sluggish and unequal pupillary responses
C. Increased head circumference and bulging fontanels
D. Blood pressure fluctuations and syncope -
✔✔ANSW✔✔..B. Sluggish and unequal pupillary
responses
A client with acute pancreatitis is admitted with severe,
piercing abdominal pain and an elevated serum amylase.
Which additional information is the client most likely to
report to the nurse?
A. Abdominal pain decreases when lying supine
B. Pain lasts an hour and leaves the abdomen tender
C. Right upper quadrant pain refers to right scapula
D. Drinks alcohol until intoxicated at least twice weekly. -
✔✔ANSW✔✔..A. Abdominal pain decreases when lying
supine
, A child newly diagnosed with sickle cell anemia (SCA) is
being discharged from the hospital. Which information is
most important for the nurse to provide the parents prior
to discharge?
A. Instructions about how much fluid the child should
drink daily.
B. Signs of addiction to opioid pain medications
C. Information about non-pharmaceutical pain relief
measures
D. Referral for social services for the child and family -
✔✔ANSW✔✔..A. Instructions about how much fluid the
child should drink daily
1. A male client with stomach cancer returns to the
unit following a total gastrectomy. He has a
nasogastric tube to suction and is receiving Lactated
Ringer's solution at 75 mL/hour IV. One hour after
admission to the unit, the nurse notes 300 mL of blood
in the suction canister, the client's heart rate is 155
beats/minute, and his blood pressure is 78/48 mmHg.
In addition to reporting the finding to the surgeon.
Which action should the nurse implement first?
d. Increase the infusion rate of Lactated Ringer's solution.
2. an adult male who fell 20 feet from the roof of this
home has multiple injuries, including a right
pneumothorax. Chest tubes were inserted in the
emergency department prior to his transfer to the
intensive care unit (ICU). the nurse notes that the
suction control chamber is bubbling at the