Nokea
A client is admitted from the emergency department after falling down a flight of stairs at home. Her vital signs are stable and her history states that she had a gastric stapling 2 years ago and takes neomycin for acne. The client jokes about how she is clumsy lately and trips over things. The nurse should ask the client which of the following questions? Select all that apply.
- A. Are you experiencing numbness in your extremities?'
- B. How much vitamin B12 are you getting?'
- C. Are you feeling depressed?'
- D. Do you feel safe at home?'
- E. Are you getting sufficient iron in your diet?'
Correct Answer: A,B,D
Rationale: Gastric stapling can impair vitamin B12 absorption, and neomycin may further reduce B12 levels by altering gut flora. The client's clumsiness and falls suggest possible B12 deficiency neuropathy, warranting questions about numbness and B12 intake. Asking about safety at home is crucial to assess for environmental or abuse-related causes of falls. Depression and iron intake are less directly related to the symptoms described.
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The rapid response team has been called to manage an unwitnessed cardiac arrest. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is:
- A. 1 to 2 minutes.
- B. 4 to 6 minutes.
- C. 8 to 10 minutes.
- D. 12 to 15 minutes.
Correct Answer: B
Rationale: Brain damage begins after 4 to 6 minutes without oxygenation, making this the critical window for initiating CPR to prevent permanent damage.
A client who is recovering from gastric surgery is receiving I.V. fluids to be infused at 100 mL/hour. The I.V. tubing delivers 15 gtt/mL. The nurse should infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour?
Correct Answer: 25 gtt/minute
Rationale: To calculate: (100 mL/hour × 15 gtt/mL) ÷ 60 minutes/hour = 25 gtt/minute. The nurse should set the flow rate to 25 drops per minute.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
The nurse in the intensive care unit is giving a report to the nurse in the post-surgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to:
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is communicated consistently and reduces the risk of omissions during the report.
The nurse is performing a physical assessment on a client. To assess the client's visual acuity, the nurse would use a
- A. Snellen chart.
- B. tonometer device.
- C. penlight.
- D. slit lamp.
Correct Answer: A
Rationale: The Snellen chart is used to assess visual acuity by testing distance vision. A tonometer measures intraocular pressure, a penlight examines pupil response, and a slit lamp evaluates eye structures.