Nokea
A nurse assesses a client and notes the client's position as indicated in the illustration below: How should the nurse document this finding?
- A. Decorticate posturing
- B. Decerebrate posturing
- C. Flaccid posturing
- D. Spinal cord degeneration
Correct Answer: A
Rationale: Decorticate posturing indicates corticospinal pathway interruption, a serious finding requiring immediate documentation and reporting. The other options do not accurately describe this abnormal posture.
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A nurse is caring for a client with a history of renal insufficiency who is scheduled for a computed tomography scan of the head with contrast medium. Which priority intervention should the nurse implement?
- A. Educate the client about strict bedrest after the procedure.
- B. Obtain a prescription for intravenous fluids.
- C. Assess the client's gag reflex.
- D. Insert an indwelling urinary catheter.
Correct Answer: B
Rationale: Intravenous fluids promote excretion of contrast medium, protecting the kidneys in clients with renal insufficiency. Bedrest is not required, gag reflex is unaffected, and an indwelling catheter is unnecessary unless otherwise indicated.
A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next?
- A. Touch the pin on the same area of the left hand.
- B. Contact the provider with the assessment results.
- C. Document the findings and end the assessment.
- D. Continue the assessment on the client's feet.
Correct Answer: A
Rationale: After confirming normal pain sensation on the right hand, the nurse should assess the left hand to ensure bilateral symmetry before moving to other areas like the feet. The finding is normal and does not require immediate reporting.
A nurse plans care for an 83-year-old client who is experiencing age-related sensory perception changes. Which intervention should the nurse include in this client's plan of care?
- A. Provide a call button that requires only light pressure to activate.
- B. Ensure the path to the bathroom is free from equipment.
- C. Encourage the client to season food to stimulate nutritional intake.
- D. Provide written instructions in large print for the client.
Correct Answer: B
Rationale: Clearing the path to the bathroom ensures safe ambulation for a client with sensory perception changes, reducing fall risk. The other options do not directly address the safety concerns related to impaired sensory perception.
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 assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact?
- A. A young girl wrapped in a shroud fell asleep on a bed of clouds.
- B. I was born on April 3, 1967, in Johnstown Community Hospital.
- C. Apple, chair, and pencil are the words you just stated.
- D. I ate oatmeal with wheat toast and orange juice for breakfast.
Correct Answer: D
Rationale: Asking clients about recent events that can be verified, such as what they ate for breakfast, assesses recent memory. The other options assess different cognitive functions: making up a rhyme tests higher cognition, recalling birth details tests remote memory, and repeating words tests immediate memory.