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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.
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A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition is most likely?
- A. Difficulty with proprioception
- B. Peripheral motor disorder
- C. Impaired cerebral function
- D. Positive pronator drift
Correct Answer: A
Rationale: A positive Romberg's sign with eyes closed but not with eyes open indicates difficulty with proprioception, as the client relies on vision to compensate for impaired position sense. The other options do not specifically describe this clinical finding.
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.
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.
A nurse is teaching a client with cerebellar function impairment. Which statement should the nurse include in this client's teaching?
- A. Connect a light to flash when your doorbell rings.
- B. Label your faucet knobs with hot and cold signs.
- C. Ask a friend to drive you to your follow-up appointments.
- D. Use a natural gas detector with an audible alarm.
Correct Answer: B
Rationale: Cerebellar impairment affects coordination and balance, not vision or hearing, so labeling faucets helps the client safely navigate daily tasks. The other options address sensory impairments unrelated to cerebellar dysfunction.
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.