Nokea
An unconscious client has left-sided paralysis. Which intervention should the nurse implement to best prevent foot drop?
- A. Ensure that the feet are firmly against the footboard.
- B. Use pillows to elevate the legs and support the soles.
- C. Perform range of motion to the legs and feet daily.
- D. Apply a foot boot brace, 2 hours on and 2 hours off.
Correct Answer: D
Rationale: Pressure exerted on the soles of the feet when placed firmly against the footboard can impair circulation and lead to skin breakdown. Pillows provide inadequate support to prevent plantar flexion (foot drop). Performing ROM daily helps to maintain muscle tone, but it is inadequate to prevent plantar flexion when the client is in bed. Applying a foot boot brace provides good support to prevent foot drop. Removing and reapplying it every two hours allows for pressure reduction and promotes circulation.
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The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?
Correct Answer: 4 gtts/min
Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.
The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client’s plan of care?
- A. Tell the client to remain on bedrest.
- B. Maintain the intravenous rate at 150 mL/hour.
- C. Provide a soft, bland diet with three (3) snacks per day.
- D. Place the client on seizure precautions.
Correct Answer: D
Rationale: Brain tumors increase seizure risk, so seizure precautions (D) are essential. Bedrest (A) is unnecessary unless indicated, IV rate (B) depends on status, and diet (C) is not specific to intracranial regulation.
The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first?
- A. Elevate the head of the bed 30 degrees.
- B. Administer oxygen via nasal cannula.
- C. Assess the client’s lung sounds.
- D. Obtain a pulse oximeter reading.
Correct Answer: B
Rationale: Dyspnea in ALS indicates respiratory distress. Administering oxygen (B) addresses hypoxia immediately. Elevating HOB (A), assessing lung sounds (C), and pulse oximetry (D) follow to support respiratory status.
When the nurse monitors the client's neurologic status, which finding is most suggestive that the client's intracranial pressure is increasing?
- A. Widening pulse pressure
- B. Increased respiratory rate
- C. Elevated temperature
- D. Decreased level of consciousness
Correct Answer: A
Rationale: Widening pulse pressure is a hallmark sign of increasing intracranial pressure, often accompanied by bradycardia (Cushing's triad).
The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?
- A. The client has cogwheel rigidity when moving the upper extremities.
- B. The client has a decrease in the frequency and severity of tremors.
- C. The client has less facial pain and converses with more facial expression.
- D. The client no longer experiences auras or a severe frontal headache.
Correct Answer: B
Rationale: Cogwheel rigidity, a symptom of PD, is interrupted muscular movement and is not treated with the DBS. DBS is a treatment used for intractable tremors associated with PD. The electrical current interferes with the brain cells initiating the tremors. Severe facial pain is associated with trigeminal neuralgia, not PD rau. The DBS will not affect facial expression. Auras are unusual sensations experienced before a seizure occurs and are not associated with PD.