The nurse is completing B. Sluggish and unequal pupillary responses
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
A client with acute A. Abdominal pain decreases when lying supine
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.
A child newly diagnosed A. Instructions about how much fluid the child
with sickle cell anemia should drink daily
(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
To auscultate for a I placed the red dot on the base of the neck on the
carotid bruit, the nurse right side
places the stethoscope
at what location. (Select
the location on the image
with a red dot).
After receiving report on D. The client with a bowel obstruction due to a
an inpatient acute care volvulus who is experiencing abdominal rigidity
unit, which client should
the nurse assess first?
A. The client with an
obstruction of the large
intestine who is
experiencing abdominal
distention
B. The client who had
surgery yesterday and is
experiencing a paralytic
ileus with absent bowel
sounds
C. The client with a small
bowel obstruction who
has a nasogastric tube
that is draining greenish
fluid
D. The client with a bowel
obstruction due to a
volvulus who is
experiencing abdominal
rigidity
A teenager presents to D. Respiratory alkalosis
the emergency
department with
palpitations after vaping
at a party. The client is
anxious, fearful, and
hyperventilating. The
nurse anticipates the
client developing which
acid base imbalance?
A. Respiratory acidosis
B. Metabolic alkalosis
C. Metabolic acidosis
D. Respiratory alkalosis
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