Nokea
After receiving report, the nurse working on the step-down neurological unit begins care for four clients. Prioritize the order in which the nurse should assess the four clients.
- A. 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering
- B. 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP
- C. 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation
- D. 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse.
Correct Answer: C,A,B,D
Rationale: The 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation. The nurse should assess the newly admitted client first to determine whether there are changes in level of consciousness and any early signs of increased ICP. The 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering. This client should be assessed next because the client is postoperative day 1, but stable. The 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP. This client has a self-limiting condition and likely wants to be discharged; thus, he or she should be assessed third. The 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse. This client can be assessed last because another nurse is in the room with the client administering the plasmapheresis treatment.
You may also like to solve these questions
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.
- A. Avoid twisting or jerking the back.
- B. Wear a soft back brace at all times.
- C. Avoid sitting for long periods during the first week.
- D. Bend from the waist when picking up items from the floor.
- E. Monitor urine output for the first week.
- F. Report lower extremity color changes to the physician.
Correct Answer: A,C,F
Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.
The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
- A. Places a suction catheter in the client’s oral cavity to stimulate the cough reflex
- B. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough
- C. Cups the hands and percusses the client’s anterior, lateral, and posterior lung fields
- D. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen
- E. Elevates the head of the bed to a high Fowler’s position if the client is sitting in bed
Correct Answer: B,E
Rationale: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse’s hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.
The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
- A. Crackles in the upper lung fields and jugular vein distention.
- B. Muscle weakness in the upper extremities and ptosis.
- C. Exaggerated arm swinging and scanning speech.
- D. Masklike facies and a shuffling gait.
Correct Answer: D
Rationale: Masklike facies and shuffling gait (D) are hallmark signs of Parkinson’s due to bradykinesia and rigidity. Crackles and JVD (A) suggest heart failure, weakness and ptosis (B) indicate myasthenia gravis, and exaggerated arm swinging (C) is opposite to Parkinson’s.
The nurse is teaching the client who is scheduled for an outpatient EEG. Which instruction should the nurse include?
- A. Remove all hairpins before coming in for the EEG test.
- B. Avoid eating or drinking at least 6 hours prior to the test.
- C. Some hair will be removed with a razor to place electrodes.
- D. Have blood drawn for a glucose level 2 hours before the test.
Correct Answer: A
Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results. The client should not be NPO since a usual glucose level is important for normal brain functioning. The scalp will not be shaved; the electrodes are applied with paste. There is no indication to have a serum glucose drawn before the test.