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A client is in the intensive care unit, admitted with a subdural hematoma. Just before shift change, as the nurse prepares to provide a bedside clinical hand-off and report, an alarm goes off, indicating a drop in the client's blood pressure. The initial action of the nurse would be:
- A. Turn the alarm off and inform the oncoming nurse of the drop in the client's blood pressure.
- B. Lower the blood pressure alarm limits on the monitor to allow for an uninterrupted bedside clinical hand-off and report.
- C. Perform the bedside clinical hand-off and report, including information regarding the client's blood pressure drop.
- D. Assess the client and intervene as needed.
Correct Answer: D
Rationale: Assessing and intervening for a blood pressure drop is the priority to ensure patient safety.
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The nurse is caring for a client who has an exacerbation of Bell's palsy and is experiencing paralysis of their eye. Which of the following actions should the nurse take?
- A. Tape an eye patch to the affected eyelid at all times.
- B. Instruct the client to keep both eyes closed.
- C. Assess the pupil's size and reactivity to light.
- D. Apply the prescribed ocular lubricant to the affected eye.
Correct Answer: D
Rationale: Ocular lubricant prevents corneal damage in Bell's palsy due to impaired eye closure.
The nurse is caring for a client eight hours postoperative following spinal surgery. Which action is essential for the nurse to take?
- A. Assess the client's pain while they receive patient-controlled analgesia (PCA)
- B. Log roll the client when turning the client from side to side
- C. Assist the client with ambulation to the bathroom
- D. Place pillows under the thighs of each leg when the client is supine
Correct Answer: B
Rationale: Log rolling maintains spinal alignment, preventing injury post-spinal surgery.
The following scenario applies to the next 1 items
The nurse in the clinic is caring for a 46-year-old female
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Nurses' Notes
0855: Client was brought to the clinic by her husband, who reports that she has been falling frequently, having difficulty remembering things, and numbness and tingling in the lower extremities. Onset was 2 weeks ago, with the falling and memory impairment worsening over the past week. The client was hospitalized 3 weeks ago because she ran out of medication, and her atrial fibrillation was giving her 'palpitations and shortness of breath.' Since refilling her medication, she has had no palpitations, chest discomfort, or dyspnea. The client's husband reports that he is worried about his wife's drinking because it has increased from three beers a day to five or six. She reports that her last drink was four days ago. On assessment, the client is alert and oriented to person, place, and time. Some speech latency was noted in her response. Her gait is unsteady, and had to be assisted to the examination room. Pupils are equal, round, and reactive to light with nystagmus. Skin is warm to touch and a normal color for ethnicity. Breathing is unlabored, and lung sounds are clear bilaterally. She reports occasional nonproductive cough. Bowel sounds present in all four quadrants. Peripheral pulses 2+ and irregular. Vital signs: T 97°F (36°C), P 72, RR 14, BP 136/78, pulse oximetry reading 97% on room air. Denies any pain, but reports tingling in her lower extremities.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two (2) parameters the nurse should monitor to assess the client's progress: Condition
- A. Start a peripheral vascular access device
- B. Wernicke encephalopathy
- C. Transient ischemic attack
- D. Alcohol withdrawal
- E. Obtain a prescription for thiamine
- F. Lower extremity paresthesias
- G. Gait
Correct Answer: A,B,E,F,G
Rationale: Wernicke encephalopathy is likely due to memory impairment, ataxia, and nystagmus in the context of alcohol use. Thiamine is critical for Wernicke encephalopathy, and IV access facilitates its administration. Monitoring gait and level of consciousness assesses improvement in Wernicke encephalopathy.
The nurse is caring for an older adult with advanced dementia. The client asks about her deceased sister, 'When will my sister come to visit me this afternoon?' Which is the best response from the nurse?
- A. This is so sad. I'm sorry to tell you but your sister died last year.'
- B. She won't be coming to visit today.'
- C. I understand you want her to visit you. Where did you and your sister grow up?'
- D. Wait and see if she comes to visit today.'
Correct Answer: C
Rationale: Redirecting the conversation compassionately avoids distress and engages the client with dementia.
The nurse is caring for a client with Bell's palsy. Which of the following prescriptions should the nurse anticipate administering to the client?
- A. Modafinil
- B. Prednisone
- C. Doxycycline
- D. Acyclovir
- E. Sumatriptan
Correct Answer: B,D
Rationale: Prednisone reduces inflammation, and acyclovir treats potential viral causes in Bell's palsy.