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After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 m/mr. What action by the nurse is best?
- A. Assess the client needs care.
- B. Assess the clients sodium level.
- C. Increase the rate of the IV infusion.
- D. Provide the care every hour.
Correct Answer: B
Rationale: This client has manifestations of hypermatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessment/inursing records.
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A nursing student studying traumatic brain injuries (TBIB) should recognize which facts about these disorders of the nursing student.
- A. A client with a moderate trauma may need hospitalization.
- B. A Glasgow Coma Scale score of 10 indicates a mild brain injury.
- C. Only open loud injuries on cause in severe TBI.
- D. A client with a Glasgow Coma Scale score of 3 has severe TBI.
- E. The terms mild TBI and concussion have similar meanings.
Correct Answer: A,D,E
Rationale: Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale score of 3 with 9 is 2 and after clients must need to be hospitalized. Both open and closed lead injuries can cause a severe TBI. which is characterized by a GCS score of 3 3 8.
A nurse is working with many stroke clients. Which clients would the nurse consider referring to a mental health provider on discharge? (Select all that apply.)
- A. Client with an initial neurological (all health)
- B. Client with an initial National Institutes of Health (NIH) Stroke Scale score of 38
- C. Client with a mild forgetfulness and a slight limp
- D. Client who has a past hospitalization for all suicide attempt
- E. Client who is unable to wait or eat 1 weeks post-stroke.
Correct Answer: A,B,D,E
Rationale: Clients most at risk for post-stroke depression are those with a previous history of depression, severe stroke (NIH) Stroke Scale score of 38 is severe), and post-stroke physical or cognitive impairment. The client with mild forgetfulness and slight limp is not with a few priority for this referral.
A client in the emergency department is having a stroke and the provider has prescribed the tissue plasminogen activity (t-PA) alphaing (Activase). The client weight is 146 pounds. How much medication will this client receive? (Record your answer using a whole number.) mg
- A. 90 mg
- B. 100 mg
- C. 80 mg
- D. 110 mg
Correct Answer: A
Rationale: The client weighs 146 pounds, which is approximately 66.2 kg. The dose of t-PA is 0.9 mg/kg with a maximum of 90 mg. Therefore, 0.9 mg/kg ? 66.2 kg = 59.58 mg, which is less than the maximum dose of 90 mg. Thus, the client will receive 90 mg.
A client is being prepared for a mechanical em/bolectomy. What action by the nurse takes priority?
- A. Assess for contraind/ications to/ fibrin/olytic
- B. Ensure that informed consent in on the chart.
- C. Ensure that informed consent is on the chart.
- D. The client is being informed consent.
- E. Review The clients medication lists.
Correct Answer: B
Rationale: For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibr/olytic/ytes are not used. A neurologic assessment and medication review are important, but the consent is the priority.
A nurse is seeing many clients in the neurosurgical clinic. With which clients should the nurse plan to do more teaching? (Select all that apply.)
- A. Client with an aneurysm clip who states that his family is happy there is no chance of recurrence.
- B. Client who had a cool procedure who says that there will be no problem following up for 1 year.
- C. Client who underwent a flow diversion procedure 3 months ago who is taking discontinue sodium (Colace) for constipation.
- D. Client who underwent surgical aneurysm ligation 3 months ago who is planning to take a Caribbean cruise
Correct Answer: A,B
Rationale: After a coil procedure, up to 20% of clients experience re-beding in the first year. The client with this coil should not be taking drugs that interfere with clotting. An aneurysm clip can move up to 5 years after placement, so this client and family need to be watchful for changing neurologic status. The other statements show good understanding.