Nokea
Before requesting the clear liquids prescribed by the physician, which assessment information is essential for the nurse to know?
- A. The client's ability to raise the head
- B. The client's preferences of clear liquids
- C. Whether the client's bowel sounds have returned
- D. The client's ability to swallow effectively
Correct Answer: D
Rationale: Assessing the ability to swallow ensures safety when initiating oral intake post-craniotomy.
You may also like to solve these questions
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem 'altered cerebral tissue perfusion'?
- A. The client will be able to complete activities of daily living.
- B. The client will be protected from injury if seizure activity occurs.
- C. The client will be afebrile for 48 hours prior to discharge.
- D. The client will have elastic tissue turgor with ready recoil.
Correct Answer: B
Rationale: Altered cerebral perfusion in meningitis may lead to seizures. Protecting from injury during seizures (B) addresses this risk. ADLs (A), fever (C), and tissue turgor (D) are unrelated to perfusion.
Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?
- A. It is all right for me to drink coffee for breakfast.'
- B. My menstrual cycle will not affect my seizure disorder.'
- C. I am going to take a class in stress management.'
- D. I should wear dark glasses when I am out in the sun.'
Correct Answer: C
Rationale: Stress can trigger seizures, so stress management classes (C) indicate understanding of seizure precipitants. Coffee (A) may increase seizure risk, menstrual cycles (B) can affect seizures due to hormonal changes, and dark glasses (D) are unrelated unless photosensitivity is a trigger.
The client, who has type I DM, is scheduled for an MRI of the brain after an MVA. Which intervention should the nurse implement to prepare the client for the test?
- A. Make the client NPO for six hours before the MRI and hold the morning insulin dose.
- B. Inform the client that the machine is noisy and that earplugs can be worn during the test.
- C. Explain that the extremity used for injection must remain straight for a few hours after MRI.
- D. Ensure that the serum BUN and creatinine levels are obtained and evaluated prior to the MRI.
Correct Answer: B
Rationale: Clients undergoing positron emission tomography (PET) scans are made NPO and have insulin held, but not those undergoing MRI. Clients are given earplugs to wear while undergoing the test because the machine makes a loud clanging noise that is unpleasant. Clients undergoing cerebral angiography, not MRI, must be on bedrest with the extremity used for injection straight for several hours after the test. Serum BUN and creatinine levels to assess renal function are required before CT scans or other tests involving contrast material to prevent renal complications.
The nurse should place the client in which position?
- A. Knee-chest (genupectoral) position
- B. Sitting in an orthopneic position
- C. Side-lying position with his neck flexed
- D. Prone position with the head turned to the left side
Correct Answer: C
Rationale: The side-lying position with the neck flexed facilitates access to the lumbar spine for a lumbar puncture and helps open the intervertebral spaces.
Which is a common cognitive problem associated with Parkinson’s disease?
- A. Emotional lability.
- B. Depression.
- C. Memory deficits.
- D. Paranoia.
Correct Answer: B
Rationale: Depression (B) is a common cognitive/emotional problem in Parkinson’s due to dopamine dysregulation and chronic illness impact. Emotional lability (A) is less common, memory deficits (C) occur later, and paranoia (D) is not typical.