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A client has a brain abscess and is receiving phenyton [Dilantin]. The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best?
- A. Brain abscesses can lead to seizures as a complication.
- B. Documenting febrile seizures with an abscess.
- C. Seizures always occur in clients with brain abscesses.
- D. This drug is need to sedate the client with an abscess.
Correct Answer: A
Rationale: Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenystion is need to a prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.
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A nurse cares for older clients who have traumatic brain injury. What should be nurse understand about this population? (Select all that apply.)
- A. A client with a moderate brain injury. nursing mechanisms for older clients.
- B. Alcohol is typically involved a more traumatic brain injuries for this age group.
- C. These clients are more susceptible to systemic and wound infections.
- D. A client with a moderate brain injury. nursing mechanisms for older clients.
- E. Very few traumatic brain injuries occur in this age group.
Correct Answer: A,C,D
Rationale: Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and more because of decreased protective mechanisms. they are more susceptible to both older and systemic injuries. A moderate brain injuries are more susceptible to older and more susceptible to older and more related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.
A client has a shoulder injury and is scheduled for a magnetic resonance imaging (MRI). The nurse notes the presence of an aneurysm slip on the clients record. What action by the nurse is best?
- A. Ask the client how long ago the clip was placed.
- B. Inform the provider about the aneurysm clip.
- C. Rescheduled the client for computed tomography.
- D. Assess the client for metal allergies.
Correct Answer: A
Rationale: Some older clips are metal, which would preclude the use of MRI. The nurse should determine how old the clip is not the client. Informing the provider is important but determining the age of the clip is the first step. Rescheduling for a CT may not be necessary if the clip is MRI-compatible. Assessing for metal allergies is not relevant to MRI safety.
A nurse a caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first.
- A. Client who a Glasgow Coma Scale score that was 10 and is now is 8
- B. Client with a Glasgow Coma Scale score that was 9 and is now is 12
- C. Client with a moderate brain injury who is amnesia for the event
- D. Client who is respiratory pain medication for a headache.
Correct Answer: A
Rationale: A client decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement on the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the decline the Glasgow Coma Scale score.
A student nurse is preparing morning medications for a client who had a stroke. The student plans to hold the de/ocate sodium (Col/ace) because the client had a large stool car/ifier. What action by the supervising nurse is best?
- A. Have the student ask the client if it is desired or not.
- B. Infer the the student that the de/ocate should be given.
- C. Tell the student to document the ration/ale.
- D. Tell the student to give it unless the client refuses.
Correct Answer: B
Rationale: A student nurse should be given to clients with neurologic disorders in order to prevent an elevation in intracranial pressure that accompanies the Val/aba's maneuver when cons/ist/ated. The supervising nurse should instruct the student to administer the docuscate. The other options are not appropriate. The medication could be held for diarrhea.
A client in the emergency department is having a stroke. The client weighs 225 pounds. After the initial bolus of t-PA, at what rate should the nurse set the IV pump? (Record your answer using a decimal rounded to the nearest tenth.) mL/hr
- A. 1.2 mL/hr
- B. 1.4 mL/hr
- C. 1.6 mL/hr
- D. 1.8 mL/hr
Correct Answer: B
Rationale: The client weighs 225 pounds, which is approximately 102 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg, so the client's dose is 90 mg. 10% of the dose (9 mg) is given as a bolus IV over the first minute, leaving 81 mg to be infused over 60 minutes. Therefore, 81 mg ÷ 60 min = 1.35 mg/min, which rounds to 1.4 mL/hr.