Nokea
A nurse assesses a client recovering from a cerebral angiography via the client's right femoral artery. Which assessment should the nurse complete?
- A. Palpate bilateral lower extremity pulses.
- B. Obtain orthostatic blood pressure readings.
- C. Perform a fundoscopic examination.
- D. Assess the gag reflex prior to eating.
Correct Answer: A
Rationale: Cerebral angiography involves threading a catheter through the femoral artery, and the extremity is immobilized post-procedure. Checking bilateral lower extremity pulses ensures adequate circulation. Orthostatic blood pressure readings are not feasible due to bedrest, and fundoscopic examination or gag reflex assessment is unrelated to the procedure.
You may also like to solve these questions
A nurse assesses a client who is recovering from a lumbar puncture (LP). Which complication should prompt the nurse to contact the health care provider?
- A. Weak pedal pulses
- B. Nausea and vomiting
- C. Increased thirst
- D. Hives on the chest
Correct Answer: B
Rationale: Nausea, vomiting, severe headache, photophobia, or altered consciousness post-LP indicate increased intracranial pressure, requiring immediate provider notification. The other findings are not specific to LP complications.
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.
A nurse delegates care for a client with cranial nerve II impairment to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client's care?
- A. Tell the client where food items are on the meal tray.
- B. Assist the client with ambulation to the bathroom.
- C. Check the client's skin for pressure ulcers daily.
- D. Provide the client with a whiteboard to communicate.
Correct Answer: A
Rationale: Cranial nerve II (optic nerve) impairment causes vision loss, so describing food placement on the tray helps the client eat independently. The other options address unrelated issues like mobility or communication.
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which client statement indicates a correct understanding of the teaching?
- A. I must increase my fluids because of the dye used for the MRI.
- B. My urine will be radioactive so I should not share a bathroom.
- C. I can return to my usual activities immediately after the MRI.
- D. My gag reflex will be tested before I can eat or drink anything.
Correct Answer: C
Rationale: No post-procedure restrictions are imposed after an MRI, allowing the client to resume normal activities. No dyes or radioactive materials are used, and the gag reflex is unaffected by the procedure.
A nurse cares for a client who is experiencing deteriorating neurologic function. The client states, 'I am worried I will not be able to care for my young children.' How should the nurse respond?
- A. Caring for your children is a priority. You may not want to ask for help, but you have to.
- B. Our community has resources that may help you with household tasks so you have energy to care for your children.
- C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
- D. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Correct Answer: D
Rationale: Exploring the client's specific concerns allows the nurse to tailor interventions and provide appropriate support. The other options make assumptions or suggest solutions without fully understanding the client's needs.