Nokea
A client is admitted to the emergency room after falling down a flight of stairs. Initial assessment reveals a large bump on the front of the head and a 2-inch laceration above the right eye. Which finding is consistent with injury to the frontal lobe?
- A. Complaints of blindness
- B. Decreased respiratory rate and depth
- C. Failure to recognize touch
- D. Inability to identify sweet taste
Correct Answer: C
Rationale: The frontal lobe is involved in sensory processing and cognition, so failure to recognize touch (agnosia) is consistent with frontal lobe injury.
You may also like to solve these questions
The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
- A. Fluid volume deficit
- B. Alteration in body image
- C. Impaired oxygen exchange
- D. Alteration in elimination
Correct Answer: A
Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.
The nurse is making assignments for the day. The staff consists of an RN, a novice RN, an LPN, and a nursing assistant. Which client should be assigned to the RN?
- A. A client with peptic ulcer disease
- B. A client with skeletal traction for a fractured femur
- C. A client with an abdominal cholecystectomy
- D. A client with an esophageal tamponade
Correct Answer: D
Rationale: The client with an esophageal tamponade requires complex monitoring and intervention, best suited for an experienced RN.
The doctor has prescribed Cortone (cortisone) for a client with systemic lupus erythematosis. Which instruction should be given to the client?
- A. Take the medication 30 minutes before eating.
- B. Report changes in appetite and weight.
- C. Wear sunglasses to prevent cataracts.
- D. Schedule a time to take the influenza vaccine.
Correct Answer: B
Rationale: Cortisone can cause weight gain and appetite changes, which should be monitored in SLE to manage side effects.
The nurse is reviewing medication orders for his clients. Which order would necessitate contacting the health care provider?
- A. Paxil (paroxetine) 20 mg PO daily for a 57-year-old client with social anxiety disorder
- B. Phenergan (promethazine hydrochloride) 12.5 mg PR q12h prn for a child with Reye's syndrome
- C. Diflucan (fluconazole) 150 mg x 1 dose PO for a 24-year-old client with vaginal candidiasis
- D. Lopressor (metoprolol tartrate) 50 mg PO daily for a 48-year-old client with hypertension
Correct Answer: B
Rationale: Promethazine is contraindicated in children with Reye’s syndrome due to the risk of worsening neurological symptoms. Other orders are appropriate.
A client has had a recent below-knee (BK) amputation of the right leg because of a traumatic injury. After removing the elastic wrap, which the client had applied, the nurse notes an unusual pattern of swelling. Which of the following is the most likely reason for this observation?
- A. Wound infection
- B. Impaired circulation to the stump
- C. Incorrect wrap technique
- D. Bleeding into the tissues
Correct Answer: C
Rationale: An unusual swelling pattern after removing an elastic wrap suggests incorrect wrap technique (C), which can cause uneven pressure. Infection (A), impaired circulation (B), or bleeding (D) would present differently.