Nokea
A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported?
- A. Position him in a prone position and place on a backboard.
- B. Apply a neck collar and position supine on a backboard.
- C. Log roll him to a rigid backboard.
- D. Position in an upright position with a firm neck collar.
Correct Answer: B
Rationale: A suspected neck injury requires immobilization with a neck collar and supine positioning on a backboard to prevent further spinal cord damage.
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Which ototoxic medication should the nurse recognize as potentially life altering or threatening to the client?
- A. An oral calcium channel blocker.
- B. An intravenous aminoglycoside antibiotic.
- C. An intravenous glucocorticoid.
- D. An oral loop diuretic.
Correct Answer: B
Rationale: Aminoglycosides (e.g., gentamicin) are ototoxic, causing permanent hearing loss, which is life-altering. Calcium channel blockers, glucocorticoids, and loop diuretics are less ototoxic.
The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
- A. Aspiration pneumonia
- B. Decubitus ulcers
- C. Bladder distention
- D. Hypertensive crisis
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.
Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?
- A. Move the big toe up and down and ask in which direction the vibration is felt.
- B. Place a tuning fork on the big toe and ask if the vibrations are felt.
- C. Tap the client's cheek with the finger and determine if vibrations are felt.
- D. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.
Correct Answer: B
Rationale: Placing a tuning fork on the big toe assesses vibration sense (via dorsal column pathways), not cranial nerves directly, but is the correct technique. Other options assess different sensations.
Which recommendation should the nurse suggest to an elderly client who lives alone when discussing normal developmental changes of the olfactory organs?
- A. Suggest installing multiple smoke alarms in the home.
- B. Recommend using a night-light in the hallway and bathroom.
- C. Discuss keeping a high-humidity atmosphere in the bedroom.
- D. Encourage the client to smell food prior to eating it.
Correct Answer: A
Rationale: Olfactory decline reduces smoke detection, making multiple smoke alarms critical for safety. Night-lights address vision, humidity is unrelated, and smelling food is unreliable.
Which assessment technique should the nurse use to assess the client's optic nerve?
- A. Have the client identify different smells.
- B. Have the client discriminate between sugar and salt.
- C. Have the client read the Snellen chart.
- D. Have the client say 'ah' to assess the rise of the uvula.
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.