Nokea
The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
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The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
- A. Brain CT scan results show no bleeding.
- B. Had a serious head injury four weeks ago.
- C. Has a history of type 1 diabetes mellitus.
- D. Neurological deficits started 2 hours ago.
Correct Answer: B
Rationale: A negative CT scan is a criterion for administering the thrombolytic therapy. Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage. History of type 1 DM is not a contraindication for thrombolytic therapy. The onset of neurological deficits within 3 hours is a criterion for administering thrombolytic therapy.
If the client begins to have a seizure after the EEG, which action should the nurse take first?
- A. Administer oxygen by nasal cannula.
- B. Measure the blood pressure and pulse.
- C. Check the client's pupils.
- D. Place the client in a side-lying position.
Correct Answer: D
Rationale: Placing the client in a side-lying position prevents aspiration and maintains airway patency during a seizure.
The client is prescribed a loading dose of phenytoin of 15 mg/kg IV for seizure activity, then 100 mg IV tid. The client weighs 198 lb. What dose in mg should the nurse administer for the loading dose of phenytoin?
- A. 1350 mg IV
Correct Answer: 1350
Rationale: 198 lb = 90 kg; (198 ÷ 2.2 = 90 kg; 90 x 15 = 1350) The nurse should administer 1350 mg phenytoin (Dilantin).
Which assessment finding in a client post-diskectomy indicates a potential complication?
- A. Mild incisional pain
- B. Numbness in the toes
- C. Clear urine output
- D. Stable vital signs
Correct Answer: B
Rationale: Numbness in the toes may indicate nerve compression or damage, a potential complication requiring further evaluation.
The client underwent a lumbar laminectomy with spinal fusion 12 hours earlier. Which nursing assessment finding indicates that the client has a leakage of CSF?
- A. Backache not relieved by narcotic analgesics
- B. 50 mL of serosanguineous fluid in the bulb drain
- C. Clear fluid drainage noted on the surgical dressing
- D. Sudden spike in temperature to 101.3°F (38.5°C)
Correct Answer: C
Rationale: Unrelieved back pain may be associated with another complication, not CSF leakage. A severe headache, rather than back pain, may be associated with CSF leakage. 50 mL of serosanguineous fluid in the bulb drain is a normal finding. Clear drainage on the surgical dressing is indicative of a CSF leak. The temperature elevation could indicate an infection.