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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.
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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.
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 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 assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
- A. Glasgow Coma Scale score changes
- B. Abnormal flexion or extension
- C. Changes in cognition or speech
- D. Pinpoint, dilated, and nonreactive pupils
- E. Stable vital signs
Correct Answer: A,B,C,D
Rationale: Changes in Glasgow Coma Scale score, abnormal posturing, altered cognition or speech, and nonreactive pupils indicate neurological deterioration, requiring urgent provider notification. Stable vital signs do not necessitate immediate action.