Nokea
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
- A. Blood pressure 100/60 mm Hg
- B. Lethargy
- C. Nausea
- D. Periorbital edema
Correct Answer: B
Rationale: Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.
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A client the nurse is caring for experiences a seizure. What would be a priority nursing action?
- A. Restrain the client during the seizure.
- B. Insert a tongue blade between the teeth.
- C. Protect the client from injury.
- D. Suction the mouth during the convulsion.
Correct Answer: C
Rationale: The nursing action for a client experiencing a seizure should be to protect the client from being injured. To ensure this, the nurse should turn the client to one side and not restrain client's movements. Inserting a tongue blade between the teeth is not as important as protecting the client from injury. The mouth and the pharynx of the client should be suctioned only after the seizure.
The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event?
- A. Seizure began at 1300 hours.
- B. The client cried out before the seizure began.
- C. Seizure was 1 minute in duration including tonic-clonic activity.
- D. Sleeping quietly after the seizure
Correct Answer: C
Rationale: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and the skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
A client diagnosed with Huntington disease is on a disease-modifying drug regimen and has a urinary catheter in place. Which potential complication is the highest priority for the nurse while monitoring the client?
- A. Severe depression
- B. Choreiform movements
- C. Urinary tract infection
- D. Emotional apathy
Correct Answer: C
Rationale: Because all disease-modifying drug regimens for Huntington disease can decrease immune cells and infection protection, it is most important for the nurse to assess for acquired infections such as urinary tract infections, especially if the client is catheterized. Severe depression is common and can lead to suicide. Symptoms of Huntington disease develop slowly and include mental apathy and emotional disturbances, choreiform movements (uncontrollable writhing and twisting of the body), grimacing, difficulty chewing and swallowing, speech difficulty, intellectual decline, and loss of bowel and bladder control. Assessing for these other conditions is appropriate but not as important as assessing for urinary tract infection in the client on a disease-modifying drug regimen with a urinary catheter in place.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A. The client will take the seizure medication at the same time daily.
- B. The client will remain free of injury if a seizure does occur.
- C. The client will verbalize an understanding of feelings that preempt seizure activity.
- D. The client will post emergency numbers on the refrigerator for ease of obtaining.
Correct Answer: B
Rationale: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. In the early stages, people with the disease can participate in most physical activities.
- B. The disease eventually leads to hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements.
- C. Disease-modifying medications for Huntington disease can decrease immune cells and infection protection.
- D. There are specific tests that can be arranged to diagnose whether or not you have the disorder.
- E. Huntington disease is familial; it is not transmitted genetically.
Correct Answer: A,B,C
Rationale: In teaching the client about Huntington disease, the nurse will explain to the client that people with the disease can participate in most physical activities in the early stages, but that the disease eventually causes hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements. The nurse will go on to inform the client that medications for Huntington disease can decrease immune cells and immune protection. There are no specific diagnostic tests for this disorder, and it is transmitted genetically; thus, the nurse will leave out these statements in the teaching.