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A nurse obtains a focused health history for a client who is scheduled for magnetic resonance angiography. Which priority question should the nurse ask before the test?
- A. Have you had a recent blood transfusion?
- B. Do you have allergies to iodine or shellfish?
- C. Are you taking any cardiac medications?
- D. Do you currently use oral contraceptives?
Correct Answer: B
Rationale: Allergies to iodine or shellfish are critical to assess because the contrast used in magnetic resonance angiography may cause a similar allergic reaction. The other options do not affect the safety or outcome of the procedure.
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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.
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 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 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 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.