Nokea
A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alert the nurse to contact the health care provider?
- A. Shingles on the client's back
- B. Client is claustrophobic
- C. Absence of intravenous access
- D. Paroxysmal nocturnal dyspnea
Correct Answer: A
Rationale: Shingles at the puncture site increases infection risk, requiring the nurse to notify the provider. Claustrophobia, lack of IV access, or dyspnea can be managed without canceling the procedure.
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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 assesses an older client. Which assessment findings should the nurse identify as normal changes in the nervous system related to aging? (Select all that apply.)
- A. Long-term memory loss
- B. Slower processing time
- C. Increased sensory perception
- D. Decreased risk for infection
- E. Change in sleep patterns
Correct Answer: B,E
Rationale: Normal
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 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.