Nokea
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
- A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- B. Discuss the precipitating factors that caused the symptoms.
- C. Schedule for a STAT computed tomography (CT) scan of the head.
- D. Notify the speech pathologist for an emergency consult.
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
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The home health nurse evaluates the foot care of the dark-skinned African client who has peripheral neuropathy. Which client actions in providing foot care are appropriate? Select all that apply.
- A. Uses a mirror and visually inspects the feet on a daily basis
- B. Lotions the feet and legs daily, avoiding between the toes
- C. Goes barefoot when indoors to help dry and air out the feet
- D. Wears warm socks and boots when outside in cold weather
- E. Trims toenails weekly so they have a rounded contour
- F. Inspects the feet for redness and other signs of inflammation
Correct Answer: A,B,D
Rationale: Using a mirror allows for visual inspection of the bottom of the feet and between the toes for areas of skin breakdown. Keeping the skin adequately lubricated with lotion prevents drying and cracking. Lotion should not be applied between the toes because it increases moisture and the risk for infection. Clients should avoid going barefoot because this increases the risk for foot injury. Wearing appropriate clothing protects the skin from injury because sensation is diminished with peripheral neuropathy. Toenails should be trimmed straight across to avoid damaging the tissue, which is slow to heal in the presence of peripheral neuropathy. In a dark-skinned client, areas of inflammation may appear purplish-blue or violet rather than appearing reddened (erythematous).
Which clinical manifestation is the educator most likely to include as the initial sign of Parkinson's disease?
- A. Muscle rigidity
- B. Muscle tremors
- C. Muscle weakness
- D. Muscle deterioration
Correct Answer: B
Rationale: Muscle tremors, particularly resting tremors, are often the initial sign of Parkinson's disease.
Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply.
- A. Turn the client every two (2) hours.
- B. Encourage the client to increase fluids.
- C. Keep the client in the supine position.
- D. Assess for deep vein thrombosis (DVT).
- E. Assess for any alterations in elimination.
Correct Answer: A,D,E
Rationale: Turning every 2 hours (A) prevents pressure ulcers, assessing DVT (D) addresses immobility risks, and monitoring elimination (E) ensures bowel/bladder function. Increased fluids (B) depend on status, and supine positioning (C) may increase ICP.
If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?
- A. Administer another dose of the nonopioid analgesic immediately.
- B. Rearrange medication times so that the client receives pain medication hourly.
- C. Consult the physician about ordering an opioid analgesic.
- D. Use a nondrug intervention such as listening to a guided imagery tape.
Correct Answer: D
Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.
The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
- A. The elderly client who is experiencing a stroke in evolution.
- B. The client diagnosed with a transient ischemic attack 48 hours ago.
- C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
- D. The client with Alzheimer's disease who is wandering in the halls.
Correct Answer: A
Rationale: A stroke in evolution (A) is an acute, progressing condition requiring experienced monitoring. TIA (B) is stable, Guillain-Barré pain (C) is manageable, and wandering (D) needs supervision but is less acute.