Nokea
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Sticks his tongue out
- C. Frowns symmetrically
- D. Identifies a sour taste
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, is responsible for controlling the trapezius and sternocleidomastoid muscles, which are involved in shoulder shrugging. When the nurse asks the client to shrug his shoulders against resistance, she is testing the integrity of cranial nerve XI. This action allows the nurse to assess the strength and function of this particular cranial nerve.
Choices B, C, and D are incorrect because they test other cranial nerves. Sticking the tongue out (B) tests cranial nerve XII (hypoglossal nerve), frowning symmetrically (C) tests cranial nerve VII (facial nerve), and identifying a sour taste (D) tests cranial nerve IX (glossopharyngeal nerve). These actions do not involve cranial nerve XI and are therefore not indicators of its intactness.
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Which of the following interventions should the nurse include in the plan of care? Select all that apply.
- A. Increase oxygen flow rate to 4 L/min.
- B. Assess the client's breath sounds.
- C. Perform chest percussion and vibration.
- D. Place the client in a supine position.
- E. Restrict the client's fluid intake.
- F. Instruct the client to perform diaphragmatic breathing
Correct Answer: A, B, F
Rationale: The correct answers are A, B, and F. Increasing oxygen flow rate to 4 L/min helps improve oxygenation. Assessing breath sounds helps monitor respiratory status. Instructing the client to perform diaphragmatic breathing promotes effective breathing. Choices C and D are incorrect because chest percussion, vibration, and placing the client in a supine position are not appropriate interventions for respiratory care. Choice E is incorrect as fluid restriction may worsen respiratory conditions.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial to ensure the child's comfort and facilitate recovery. Administering analgesics on a scheduled basis helps maintain a consistent level of pain relief and prevents breakthrough pain. This approach is especially important in the immediate postoperative period when pain levels are typically higher. Options A, C, and D are incorrect because applying a warm compress, giving cromolyn nebulized solution, and offering clear liquids are not primary interventions for postoperative pain management in this scenario. Option D specifically is not recommended as clear liquids are usually introduced gradually to prevent complications. Providing analgesics on a scheduled basis is the best course of action to address the child's immediate postoperative pain effectively.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Urinary frequency
- D. Swelling of the face
Correct Answer: D
Rationale: The correct answer is D: Swelling of the face. At 14 weeks of gestation, facial swelling could indicate preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. This finding should be reported to the provider immediately for further evaluation and management to prevent complications for both the mother and the baby.
Other choices are incorrect because:
A: Bleeding gums are common during pregnancy due to hormonal changes and increased blood flow to the gums.
B: Faintness upon rising may be due to postural hypotension, common in pregnancy.
C: Urinary frequency is a common complaint in early pregnancy due to hormonal changes and pressure on the bladder from the growing uterus.
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at a high volume.
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices.
- D. Assess the client for suicidal ideation.
- E. Place the client in a room near the activity room
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.