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.
You may also like to solve these questions
Before the client undergoes the craniotomy, the nurse inserts a urinary catheter. How far should the catheter be inserted if the client is a male?
- A. 2'' to 4'' (5 to 10 cm)
- B. 4'' to 6'' (10 to 15 cm)
- C. 6'' to 8'' (15 to 20 cm)
- D. 8'' to 10'' (20 to 25.5 cm)
Correct Answer: D
Rationale: For a male, the urinary catheter should be inserted 8'' to 10'' to reach the bladder adequately.
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 wife of the client diagnosed with chronic alcoholism tells the nurse, 'I have to call his work just about every Monday to let them know he is ill or he will lose his job.' Which would be the nurse’s best response?
- A. I am sure that this must be hard for you. Tell me about your concerns.'
- B. You are afraid he will lose his source of income.'
- C. Why would you call in for your husband? Can’t he do this?'
- D. Are you aware that when you do this you are enabling him?'
Correct Answer: A
Rationale: Reflecting and inviting discussion (A) validates the wife’s feelings and encourages therapeutic communication. Assuming fear (B) is less open-ended, questioning her actions (C) may seem judgmental, and labeling enabling (D) could alienate her.
The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?
- A. The client complains of a headache at '3' to '4' on a 1-to-10 scale.
- B. The client has an intake of 1,000 mL and an output of 3,500 mL.
- C. The client complains of a raspy, sore throat.
- D. The client experiences dizziness when trying to get up too quickly.
Correct Answer: B
Rationale: Significant output (3,500 mL) compared to intake (1,000 mL, B) suggests diabetes insipidus, a complication of craniotomy due to pituitary dysfunction. Mild headache (A), sore throat (C), and orthostatic dizziness (D) are less concerning.
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.