Nokea
A nurse cares for several clients on a neurologic unit. Which prescription for a client should direct the nurse to ensure that a medical consent cannot be substituted before the test or procedure?
- A. Sensation measurement via the pinprick method
- B. Computed tomography of the cranial vault
- C. Lumbar puncture for cerebrospinal fluid sampling
- D. Venipuncture for autoantibody analysis
Correct Answer: C
Rationale: A lumbar puncture is an invasive procedure with potential complications, requiring informed consent. The other procedures are noninvasive and do not require consent.
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A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client's teaching?
- A. Stroke the inner aspect of your thigh to initiate voiding.
- B. Implement digital anal stimulation when your bladder is full.
- C. Tighten your abdominal muscles to stimulate urine flow.
- D. Use a catheter to empty your bladder completely.
Correct Answer: C
Rationale: In clients with lower motor neuron injuries, performing a Valsalva maneuver by tightening abdominal muscles can stimulate urine flow. The other options are not effective for achieving bladder control in this context.
A nurse assesses the health history of a client who is prescribed ziconotide (Prialt) for chronic back pain. Which assessment question should the nurse ask?
- A. Are you taking a nonsteroidal anti-inflammatory drug?
- B. Do you have a history of psychiatric disorders?
- C. Do you have difficulty swallowing medications?
- D. Do you smoke cigarettes or any illegal drugs?
Correct Answer: B
Rationale: Ziconotide can cause psychiatric side effects, so assessing for a history of psychiatric disorders is crucial. The other questions are less relevant to ziconotide's safety profile.
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should the nurse address first?
- A. Associated stridor.
- B. Weak pedal pulses.
- C. Difficulty breathing.
- D. Inability to shrug shoulders.
Correct Answer: C
Rationale: Difficulty breathing indicates a potential airway obstruction, possibly due to postoperative swelling, which is a priority. Stridor and difficulty swallowing are also concerns but maintaining an airway takes precedence. Weak pedal pulses and inability to shrug shoulders are less urgent.
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client's understanding. Which statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)
- A. I will explore other ways besides intercourse to please my partner.
- B. I will not be able to have an erection because of my injury.
- C. Ejaculation may not be as predictable as before.
- D. I may urinate with ejaculation but this will not cause infection.
- E. I should be able to have an erection with stimulation.
Correct Answer: C,D,E
Rationale: Men with injuries above T6 can often have reflex erections with stimulation. Ejaculation may be less predictable and mixed with urine, which is sterile and does not cause infection. Exploring alternative intimacy methods is also appropriate.
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this work plan care?
- A. Encourage the client to stretch the back by reaching toward the toes.
- B. Massage the affected area with ice twice a day.
- C. Apply a heating pad for 20 minutes at least four times daily.
- D. Advise the client to avoid warm baths or showers.
Correct Answer: C
Rationale: Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.