Nokea
A client has undergone a percutaneous stereotactic rhizotomy. What instruction by the nurse is most important on discharge from the ambulatory surgical center?
- A. Avoid having teeth pulled for 1 year
- B. Avoid heavy lifting for 6 months
- C. Do not use harsh chemicals on your face
- D. Inform your dentist of this procedure
Correct Answer: C
Rationale: The affected side is left without sensation after this procedure. The client should avoid putting harsh chemicals on the affected side to prevent injury. The other instructions are not necessary.
You may also like to solve these questions
A client is taking long-term corticosteroids for myasthenia gravis. What teaching is most important?
- A. Avoid others who are ill
- B. Check blood sugars four times a day
- C. Use two forms of contraception
- D. Wear properly fitting socks and shoes
Correct Answer: A
Rationale: Corticosteroids reduce immune function, so clients taking these medications must avoid being exposed to illness. Long-term use can lead to secondary diabetes, but the client would not need to start checking blood glucose unless diabetes had been detected. Corticosteroids do not affect the effectiveness of contraception. While it is important to avoid injury, this is not specific to corticosteroid use.
A client with Guillian-Barr syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem?
- A. Anxiety
- B. Low fluid volume
- C. Inadequate airway
- D. Potential for skin breakdown
Correct Answer: C
Rationale: Airway takes priority. Anxiety is probably present, but a physical diagnosis takes priority over a psychosocial one. The client has no reason to have low fluid volume unless he or she has been unable to drink for some time. If present, airway problems take priority over a circulation problem. An actual problem takes precedence over a risk for a problem.
A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
- A. Assessing the client's gag reflex
- B. Cutting foods up into small bites
- C. Monitoring potassium levels
- D. Weighing the client daily
- E. Thickening liquids to prevent aspiration
Correct Answer: B,D
Rationale: Cutting food up into smaller bites makes it easier for the client to chew and swallow. The UAP can weigh the client daily to monitor nutritional status. Assessing the gag reflex and monitoring potassium levels are tasks that require nursing judgment and cannot be delegated to UAP. Thickening liquids is typically a nursing or dietary intervention, not a UAP task.
A client is receiving plasmapheresis. What action by the nurse best prevents infection in this client?
- A. Giving antibiotics prior to treatments
- B. Monitoring the client's vital signs
- C. Performing appropriate hand hygiene
- D. Placing the client in protective isolation
Correct Answer: C
Rationale: Plasmapheresis is an invasive procedure, and the nurse uses good hand hygiene before and after client contact to prevent infection. Antibiotics are not necessary. Monitoring vital signs does not prevent infection but could alert the nurse to its possibility. The client does not need isolation.
A client is admitted with Guillian-Barr syndrome (GBS). What assessment takes priority?
- A. Bladder control
- B. Cognitive perception
- C. Respiratory system
- D. Sensory functions
Correct Answer: C
Rationale: Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.