Nokea
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.
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The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?
- A. Explain that this procedure is not painful.
- B. Premedicate the client with a benzodiazepine drug.
- C. Instruct the client to shave all facial hair.
- D. Tell the client it will cause him to see 'floaters.'
Correct Answer: A
Rationale: Explaining that the EEG is painless (A) reduces anxiety. Benzodiazepines (B) are not routine, shaving (C) is unnecessary, and floaters (D) are not associated.
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.
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.
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Prepare to administer an antihistamine.
- C. Test the drainage for presence of glucose.
- D. Place a 2 x 2 gauze under the nose to collect drainage.
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (C). This is the first step to guide further action. Notifying the provider (A) follows confirmation, antihistamines (B) are irrelevant, and gauze (D) is a secondary measure.