Question

A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

Answer 1

Correct Answers:

Instruct the client to look up and down without moving his head.

Rationale :

🔷 Cranial nerve III is the oculomotor nerve, which controls most extraocular eye movements.

🔷 It is responsible for moving the eye upward, downward, and medially, making this assessment appropriate.

🔷 Cranial nerve III also controls pupil constriction and elevation of the upper eyelid.

🔷 In a client with head trauma, abnormal cranial nerve III findings may indicate increased intracranial pressure or nerve compression.

🔷 The nurse should observe for unequal pupils, ptosis, impaired eye movement, diplopia, and decreased level of consciousness.

Have the client stand with eyes closed and touch his nose.

🔷This evaluates coordination and cerebellar function.

🔷It does not specifically test cranial nerve III.

Observe the client's ability to smile and frown.

🔷Smiling and frowning assess cranial nerve VII, the facial nerve.

🔷This does not evaluate oculomotor eye movement.

Ask the client to shrug his shoulders against passive resistance.

🔷Shoulder shrug assesses cranial nerve XI, the spinal accessory nerve.

🔷It does not provide information about eye movement or pupil response.

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Answer 2

Correct Answers:

Inserting a nasogastric tube for a client

Rationale :

💎 Inserting a nasogastric tube is an appropriate task for an LPN when allowed by facility policy and state practice regulations.

💎 This task requires licensed nursing skill, knowledge of anatomy, and the ability to recognize complications.

💎 LPNs can perform certain technical procedures for stable clients under the supervision of an RN.

💎 The RN remains responsible for overall assessment, care planning, evaluation, and verifying placement according to policy.

💎 This task should not be assigned to assistive personnel because it requires clinical judgment and technical competence.

Providing postmortem care for a client

💎Postmortem care is usually a routine task that can be assigned to assistive personnel after the RN completes required assessments.

💎It does not require the technical nursing skill expected of the LPN in this assignment question.

Measuring a client's I&O

💎Measuring intake and output is appropriate for assistive personnel.

💎The nurse is responsible for interpreting abnormal trends and reporting concerns.

Obtaining a client's weight

💎Obtaining a client’s weight is a routine, noninvasive task.

💎It is appropriate for assistive personnel, while the nurse evaluates significant changes.

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Answer 3

Correct Answers:

Temporary urinary retention

Rationale :

🔶 Temporary urinary retention can occur after removal of an indwelling urinary catheter, especially in an older adult client.

🔶 While the catheter was in place, the bladder drained continuously and did not need to contract normally.

🔶 After removal, bladder tone may be reduced temporarily, making it difficult for the client to void.

🔶 The nurse should monitor the time of first void, amount voided, bladder distention, and suprapubic discomfort.

🔶 If the client cannot void within the expected timeframe, the nurse should perform a bladder scan or notify the provider according to facility policy.

Urinary frequency for several days

🔶Urinary frequency for several days is not the expected outcome after catheter removal.

🔶Persistent frequency may indicate irritation, infection, or incomplete bladder emptying.

Highly concentrated urine

🔶Highly concentrated urine is more commonly associated with dehydration.

🔶It is not an expected outcome specifically caused by catheter removal.

Blood-tinged urine

🔶Blood-tinged urine may indicate urethral trauma or irritation.

🔶It is not the expected finding after catheter removal and should be monitored if present.

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Answer 4

Correct Answers:

Administer an antiemetic.

Rationale :

🟢 Morphine commonly causes nausea and vomiting by stimulating the chemoreceptor trigger zone in the brain.

🟢 A client using a PCA pump after total hip arthroplasty should receive prescribed antiemetic therapy when nausea occurs.

🟢 Controlling nausea improves comfort and helps the client participate in deep breathing, turning, coughing, and early mobility.

🟢 Vomiting can increase pain, increase aspiration risk, and interfere with postoperative recovery.

🟢 The nurse should also continue assessing respiratory rate, sedation level, bowel function, pain relief, and PCA effectiveness.

Encourage use of the incentive spirometer.

🟢Incentive spirometry is important for preventing postoperative atelectasis.

🟢It does not directly relieve morphine-induced nausea and vomiting.

Insert a nasogastric tube.

🟢A nasogastric tube is not the first intervention for opioid-related nausea.

🟢It may be considered only for persistent vomiting, obstruction, or severe gastric distention.

Auscultate bowel sounds.

🟢Auscultating bowel sounds may help evaluate opioid-related decreased bowel motility.

🟢However, the priority action for active nausea and vomiting is administering an antiemetic.

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Answer 5

Correct Answers:

Chocolate

Rationale :

🔵 Chocolate should be avoided by clients with GERD because it can relax the lower esophageal sphincter.

🔵 When the lower esophageal sphincter relaxes, stomach acid can reflux into the esophagus.

🔵 This reflux causes symptoms such as heartburn, regurgitation, chest discomfort, cough, and sour taste.

🔵 Common GERD triggers include chocolate, peppermint, caffeine, alcohol, fatty foods, spicy foods, and acidic foods.

🔵 The client should also avoid lying down after meals, large meals, and eating close to bedtime.

Apples

🔵Apples are not a common GERD trigger for most clients.

🔵Individual tolerance varies, but apples are not the priority food to avoid.

Nonfat milk

🔵Nonfat milk is lower in fat and is less likely to worsen GERD than high-fat dairy products.

🔵Whole milk or high-fat dairy may aggravate reflux more than nonfat milk.

Oatmeal

🔵Oatmeal is usually tolerated well by clients with GERD because it is low in fat and high in fiber.

🔵It does not commonly relax the lower esophageal sphincter.

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Answer 6

Correct Answers:

Increased heart rate

Rationale :

🟣 Increased heart rate after thoracentesis can indicate a serious complication such as pneumothorax or bleeding.

🟣 Thoracentesis involves removing fluid or air from the pleural space, and lung tissue can be accidentally punctured.

🟣 If pneumothorax occurs, the client may develop tachycardia, dyspnea, chest pain, decreased breath sounds, and oxygen desaturation.

🟣 Tachycardia may be an early sign that the client is compensating for respiratory compromise or blood loss.

🟣 The nurse should immediately assess respiratory status, oxygen saturation, lung sounds, and notify the provider.

Decreased temperature

🟣A decreased temperature is not a typical immediate complication after thoracentesis.

🟣Fever later may suggest infection, but decreased temperature is not the priority concern.

Discomfort at the puncture site

🟣Mild puncture-site discomfort can be expected after thoracentesis.

🟣It should be monitored, but it is not as urgent as signs of cardiopulmonary compromise.

Serosanguineous drainage from the puncture site

🟣A small amount of serosanguineous drainage can occur after thoracentesis.

🟣Excessive bleeding, respiratory distress, or unstable vital signs would be more concerning.

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Answer 7

Correct Answers:

Cigarette smoking

Rationale :

⭐ Cigarette smoking is a modifiable risk factor for cardiovascular disease because the client can stop or reduce tobacco use.

⭐ Smoking damages blood vessel lining, promotes atherosclerosis, increases clot formation, and causes vasoconstriction.

⭐ It also reduces oxygen delivery by increasing carbon monoxide levels in the blood.

⭐ Smoking increases the risk of myocardial infarction, stroke, peripheral arterial disease, hypertension, and coronary artery disease.

⭐ The nurse should include smoking cessation counseling, nicotine replacement options, support groups, and relapse-prevention strategies.

Increasing age

⭐Increasing age is a nonmodifiable cardiovascular risk factor.

⭐The client cannot change age, but can reduce overall risk through healthy behaviors.

Diagnosis of diabetes mellitus

⭐Diabetes mellitus increases cardiovascular risk, but having the diagnosis itself is not fully modifiable.

⭐Glucose control is modifiable, but the condition is not the best answer.

Family history of cardiac disease

⭐Family history is a nonmodifiable risk factor because genetic risk cannot be changed.

⭐Clients with family history should focus on controlling modifiable risks.

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Answer 8

Correct Answers:

35 mg/dL

Rationale :

🔴 Dehydration commonly causes an elevated blood urea nitrogen, or BUN, level.

🔴 When fluid volume is low, renal blood flow decreases and urea becomes more concentrated in the bloodstream.

🔴 A BUN of 35 mg/dL is elevated and strongly supports dehydration.

🔴 Additional dehydration findings may include dry mucous membranes, poor skin turgor, tachycardia, hypotension, decreased urine output, and dark urine.

🔴 The nurse should anticipate interventions to restore fluid volume and monitor renal function, electrolytes, and intake and output.

10 mg/dL

🔴A BUN of 10 mg/dL is generally within the expected adult range.

🔴It does not suggest dehydration.

16.5 mg/dL

🔴A BUN of 16.5 mg/dL is also within the expected adult range.

🔴It is not the best finding for a dehydrated client.

3.1 mg/dL

🔴A BUN of 3.1 mg/dL is low rather than high.

🔴Low BUN may occur with liver disease, malnutrition, or overhydration.

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Answer 9

Correct Answers:

Distended bladder
Tenderness over the symphysis pubis
Voiding 30 mL frequently
Report of feeling pressure

Rationale :

Distended bladder

🟡 A distended bladder is a major sign of urinary retention.

🟡 In prostatic hypertrophy, the enlarged prostate compresses the urethra and blocks normal urine flow.

🟡 Urine remains trapped in the bladder, causing bladder enlargement.

🟡 The nurse may palpate or percuss bladder fullness in the suprapubic area.

🟡 This finding requires monitoring because prolonged retention can cause infection, bladder damage, and kidney complications.

Tenderness over the symphysis pubis

🟡 Tenderness over the symphysis pubis occurs because the bladder lies behind this area.

🟡 When the bladder becomes overdistended, pressure and discomfort develop in the lower abdomen.

🟡 This finding supports urinary retention in a client with prostatic hypertrophy.

🟡 The client may also describe pelvic pressure, urgency, or incomplete emptying.

🟡 The nurse should assess urine output, bladder distention, and postvoid residual as indicated.

Voiding 30 mL frequently

🟡 Voiding small amounts frequently can indicate overflow urinary retention.

🟡 The bladder remains full, but only small amounts leak or pass around the obstruction.

🟡 This pattern may be mistaken for urinary frequency, but it actually suggests poor bladder emptying.

🟡 Prostatic hypertrophy commonly causes weak stream, hesitancy, dribbling, nocturia, and incomplete emptying.

🟡 The nurse should monitor postvoid residual and report significant retention.

Report of feeling pressure

🟡 A feeling of pressure is expected when the bladder is overfilled with retained urine.

🟡 Pressure may be felt in the suprapubic or lower abdominal area.

🟡 This occurs because urine continues to collect behind the obstruction.

🟡 Persistent urinary retention can lead to urinary tract infection, hydronephrosis, and renal impairment.

🟡 The nurse should assess bladder status and urinary output promptly.

Dysuria

🟡Dysuria means painful or burning urination and is more commonly associated with urinary tract infection.

🟡It is not the best manifestation of urinary retention caused by prostatic hypertrophy.

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Answer 10

Correct Answers:

Serosanguineous drainage at this time is a manifestation of possible dehiscence.

Rationale :

🟠 Serosanguineous drainage 1 week after abdominal surgery can indicate possible wound dehiscence.

🟠 Dehiscence is the partial or complete separation of the surgical wound edges.

🟠 A sudden appearance or increase in pink, watery, blood-tinged drainage may occur before the incision opens.

🟠 Abdominal wounds are especially vulnerable because coughing, vomiting, obesity, infection, malnutrition, and increased abdominal pressure place tension on the incision.

🟠 The nurse should assess the wound, reduce strain on the incision, place the client in a low-Fowler’s position, cover an open wound with sterile saline-moistened gauze, and notify the provider.

Serosanguineous drainage at this time is expected after abdominal surgery.

🟠A small amount of serosanguineous drainage may be expected early after surgery.

🟠At 1 week postoperative, new or increased drainage is more concerning for impaired wound healing.

Serosanguineous drainage at this time is a manifestation of infection.

🟠Infection is usually associated with purulent drainage, redness, warmth, swelling, fever, odor, and increased pain.

🟠Serosanguineous drainage alone at this stage is more concerning for possible wound separation.

Serosanguineous drainage at this time is a manifestation of hemorrhage.

🟠Hemorrhage is usually associated with bright red bleeding, rapid drainage, hypotension, tachycardia, and signs of shock.

🟠Serosanguineous drainage is blood-tinged fluid and is more consistent with possible dehiscence in this scenario.

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QLexNursing

1 :
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

2 :
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

3 :
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

4 :
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

5 :
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

6 :
A nurse is monitoring a client following a thoracentesis .The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

7 :
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

8 :
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

9 :
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

10 :
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

QLexNursing

1 : A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

2 : At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

3 : A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

4 : A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

5 : A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

6 : A nurse is monitoring a client following a thoracentesis .The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

7 : A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

8 : A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

9 : A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

10 : A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?

1 :
A nurse is performing a neurological assessment for a client has head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve III?

2 :
At the beginning of the shift, an RN is preparing assignments for a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following tasks should the nurse assign to the LPN?

3 :
A nurse removes an indwelling urinary catheter that an older adult client has had in place for 2 days. The nurse should assess the client for which of the following expected outcomes after catheter removal?

4 :
A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?

5 :
A nurse is providing teaching for a client who has a new diagnosis of gastroesophageal reflux disease (GERD). The client asks about foods he should avoid eating. Which of the following foods should the nurse tell him to avoid

6 :
A nurse is monitoring a client following a thoracentesis .The nurse should identify which of the following manifestations as a complication and contact the provider immediately?

7 :
A nurse is preparing a community health program for adults at risk for cardiovascular disease. Which of the following should the nurse include as a modifiable risk factor?

8 :
A nurse is admitting a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have upon admission?

9 :
A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.)

10 :
A nurse is changing the dressing of a client who is 1 week postoperative following abdominal surgery and notes the presence of serosanguineous drainage. The nurse should recognize that this is an indication of which of the following circumstances?