Nokea
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse perform when educating this client about newly prescribed medications?
- A. Help the client identify each medication by its color.
- B. Provide written materials with large print size.
- C. Sit on the client's right side and speak into the right ear.
- D. Allow the client to use a white board to ask questions.
Correct Answer: C
Rationale: The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear to compensate for the hearing impairment caused by left temporal lobe damage. The other interventions do not directly address the hearing deficit associated with this condition.
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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.
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.
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 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.
After teaching a client who is scheduled for magnetic resonance imaging (MRI), the nurse assesses the client's understanding. Which client statement indicates a correct understanding of the teaching?
- A. I must increase my fluids because of the dye used for the MRI.
- B. My urine will be radioactive so I should not share a bathroom.
- C. I can return to my usual activities immediately after the MRI.
- D. My gag reflex will be tested before I can eat or drink anything.
Correct Answer: C
Rationale: No post-procedure restrictions are imposed after an MRI, allowing the client to resume normal activities. No dyes or radioactive materials are used, and the gag reflex is unaffected by the procedure.