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A nurse asks a client to take deep breaths during an electroencephalography. The client asks, 'Why are you asking me to do this?' How should the nurse respond?
- A. Hyperventilation causes vascular dilation to cerebral arteries, which decreases electrical activity in the brain.
- B. Deep breathing helps you to relax and allows the electroencephalography to obtain a better waveform.
- C. Hyperventilation causes cerebral vasoconstriction and increases the likelihood of seizure activity.
- D. Hyperventilation causes dilation of cerebral arteries, which increases the likelihood of seizure activity.
Correct Answer: C
Rationale: Hyperventilation produces cerebral vasoconstriction and alkalosis, which increases the likelihood of seizure activity, enhancing the EEG's ability to detect abnormalities. The other responses are inaccurate regarding the physiological effects of hyperventilation.
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A nurse plans care for a client who has a hypoactive response to a test of deep tendon reflexes. Which intervention should the nurse include in this client's plan of care?
- A. Check bath water temperature with a thermometer.
- B. Provide the client with assistance when ambulating.
- C. Place elastic support hose on the client's legs.
- D. Allow the client to use a white board to ask questions.
Correct Answer: B
Rationale: Hypoactive deep tendon reflexes and loss of vibration sense can impair balance and coordination, predisposing the client to falls. Providing ambulation assistance helps prevent injury by ensuring the client has support while walking. The other interventions do not address the balance and coordination issues caused by hypoactive reflexes.
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
- A. Shingles on the client's back
- B. Client is claustrophobic
- C. Absence of intravenous access
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Shingles at the puncture site increases infection risk, requiring the nurse to notify the provider. Claustrophobia, lack of IV access, or dyspnea can be managed without canceling the procedure.
A nurse obtains a focused health history for a client who is scheduled for magnetic resonance imaging (MRI). Which condition should alert the nurse to contact the provider and cancel the procedure?
- A. Creatine phosphokinase (CPK) of 100 IU/L.
- B. Atrioventricular graft.
- C. Blood urea nitrogen (BUN) of 50 mg/dL.
- D. Internal insulin pump.
Correct Answer: D
Rationale: Metal devices like an internal insulin pump can interfere with MRI imaging and be displaced by magnetic forces, necessitating cancellation. CPK, BUN levels, and atrioventricular grafts do not contraindicate MRI.
A nurse teaches a client who is scheduled for a positron emission tomography scan of the brain. Which statement should the nurse include in this client's teaching?
- A. Avoid caffeine-containing substances for 12 hours before the test.
- B. Increase your fluid intake before and after the test.
- C. Do not take your cardiac medication the morning of the test.
- D. Remove your dentures and any metal before the test begins.
Correct Answer: A
Rationale: Caffeine is a central nervous system stimulant that may alter PET scan results, so it should be avoided for 12 hours prior. Increased fluid intake is unnecessary, cardiac medications should be continued, and metal removal is relevant for MRI, not PET.
A nurse is caring for a client who is prescribed a computed tomography (CT) scan with iodine-based contrast. Which actions should the nurse take to prepare the client for this procedure? (Select all that apply.)
- A. Ask the client about any allergies
- B. Evaluate the client's renal function
- C. Ensure informed consent is present
- D. Assess breath sounds
- E. Assess hematocrit and hemoglobin levels
Correct Answer: A,B,C
Rationale: Asking about allergies (especially to iodine or shellfish), evaluating renal function, and ensuring informed consent are critical to safely administer iodine-based contrast. Assessing breath sounds or hematocrit/hemoglobin is unrelated to CT preparation.