Nokea
An adult client who had a cervical laminectomy is returned to her room on the nursing care unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. The nurse should position the client in which of the following positions?
- A. Supine
- B. Semi-reclining
- C. Side-lying
- D. Prone
Correct Answer: C
Rationale: Side-lying position promotes comfort and maintains spinal alignment post-cervical laminectomy, reducing strain on the surgical site. Supine or prone positions may increase pressure on the neck, and semi-reclining is less optimal for spinal stability.
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The nurse is caring for a client with a history of headaches who has come to the clinic reporting a 'bad migraine.' The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?
- A. Blood pressure of 136/88 mm Hg
- B. Flat affect and drowsiness
- C. Nausea and poor appetite
- D. Respiratory rate of 12/min
Correct Answer: B
Rationale: Flat affect and drowsiness in a migraine are atypical and may indicate a more serious condition like a neurological event, requiring urgent evaluation. Nausea and poor appetite are common in migraines, and the BP and respiratory rate are within normal limits.
The nurse is reinforcing instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required?
- A. I am looking forward to our summer vacation at the beach
- B. I plan to eat more fruits and vegetables to prevent constipation
- C. I should not drive until I know how this drug affects me
- D. I will drink at least 6-8 glasses of water daily
Correct Answer: A
Rationale: Planning a beach vacation suggests unawareness of oxybutynin’s heat intolerance side effect, increasing dehydration risk. Preventing constipation, avoiding driving, and adequate hydration are correct.
An adult who had a cerebrovascular accident (CVA) with expressive aphasia has started saying some words. The client's family is quite upset because the words are mostly profanity. They tell the nurse that the client usually does not use profanity. How should the nurse respond to the family?
- A. She must be in a lot of pain to use profanity. We will assess her for pain.'
- B. Many people who have had aphasia following a stroke use profanity when speech first returns. Other words will soon follow.'
- C. It is not appropriate for her to use profanity when speaking to the nurses. We will discipline her when this happens.'
- D. She must be upset with you or us. We will try to find out what is bothering her.'
Correct Answer: B
Rationale: Profanity in early expressive aphasia post-CVA is common due to disinhibition in damaged brain areas; reassuring the family that other words will follow is appropriate.
For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
- A. Institute seizure precautions
- B. Weigh the child twice per shift
- C. Encourage the child to eat protein-rich foods
- D. Relieve boredom through physical activity
Correct Answer: A
Rationale: Institute seizure precautions. The severity of AGN is unpredictable, and complications like seizures may occur due to hypertension.
A client is admitted to the burn unit with an electrical burn. Which of the following areas probably sustained the greatest degree of injury?
- A. The skin
- B. The intrathoraxic
- C. The muscles supporting the long bones
- D. The bones
Correct Answer: B
Rationale: Electrical burns cause deep tissue damage, with intrathoracic organs (heart, lungs) at greatest risk due to the current's path through the body.