Nokea
A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will:
- A. Exhibit no further episodes of short-term memory loss.
- B. Be able to return to his construction job in 3 weeks.
- C. Actively participate in the rehabilitation process as appropriate.
- D. Re campaign to the end display pre-injury personality traits.
Correct Answer: C
Rationale: Active participation in rehabilitation is a realistic and appropriate outcome, promoting recovery tailored to the client's abilities. Eliminating memory loss, returning to a physically demanding job soon, or fully restoring pre-injury personality are unrealistic due to the severity of the injury.
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A nurse assesses a 40-year-old female client with vasospastic disorder (Raynaud's phenomenon) involving her right hand. The nurse notes the information in the progress notes, as shown below. From these findings, the nurse should formulate which priority nursing diagnosis?
- A. Acute pain related to hyperemic stage
- B. Disturbed sensory perception (tactile) related to vasospastic process
- C. Ineffective tissue perfusion (peripheral) related to vasospastic process
- D. Risk for impaired skin integrity related to vasospastic process
Correct Answer: C
Rationale: Ineffective tissue perfusion (peripheral) is the priority nursing diagnosis in Raynaud's phenomenon, as vasospasm reduces blood flow to the extremities, causing ischemia. This underlies symptoms like numbness or pallor. Pain, sensory changes, or skin integrity risks are secondary to perfusion deficits.
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.
A 65-year-old male has hearing loss and a sensation of fullness in both ears. The nurse examines his ears with the understanding of the cause of hearing loss in older adults is related to:
- A. Accumulation of cerumen in the external canal.
- B. Accumulation of cerumen in the internal canal.
- C. External otitis.
- D. Exostosis.
Correct Answer: A
Rationale: Accumulation of cerumen in the external canal is a common cause of conductive hearing loss in older adults, leading to a sensation of fullness and reduced hearing.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
Which position would most help to decrease a client's discomfort when the client's spouse injects vitamin B12 using the ventrogluteal site?
- A. Lying on the side with legs extended.
- B. Lying on the abdomen with toes pointed inward.
- C. Leaning over the edge of a low table with hips flexed.
- D. Standing upright with the feet one shoulder-width apart.
Correct Answer: B
Rationale: The ventrogluteal site is best accessed when the client lies on their abdomen with toes pointed inward, as this position relaxes the gluteal muscles and minimizes discomfort during injection. The other positions do not optimally relax the muscle or provide access to the ventrogluteal site.