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Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client's plan of care?
- A. Confusion
- B. Check neuro vital signs every 4 hours.
- C. Maintain intravenous access.
- D. Keep the suture line clean and dry.
Correct Answer: C
Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.
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The client enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is arising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. What action should the nurse take?
- A. Demonstrate how to help the client move more efficiently
- B. Offer a PRN analgesic to reduce painful movement
- C. Affirm that the client should arise slowly from the chair
- D. Tell the UAP to assist the client in moving more quickly
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to demonstrate how to help the client move more efficiently. As the client is arising slowly from the chair, providing guidance on proper movement techniques can improve the client's mobility and safety. Offering a PRN analgesic (Choice B) is not relevant to the client's situation as there is no indication of pain. Affirming that the client should arise slowly (Choice C) does not address the need for assistance in improving movement efficiency. Instructing the UAP to assist the client in moving more quickly (Choice D) may compromise the client's safety and is not the appropriate action to take.
The parents of a 6-year-old recently diagnosed with asthma should be taught that the symptom of acute episodes of asthma is due to which physiological response?
- A. Inflammation of the mucous membrane & bronchospasm
- B. Increased mucus production and bronchoconstriction
- C. Allergic reactions and hyperventilation
- D. Airway narrowing and decreased lung capacity
Correct Answer: A
Rationale: The correct answer is A: Inflammation of the mucous membrane & bronchospasm. Acute asthma episodes are primarily caused by inflammation of the airways and bronchospasm, which lead to airway obstruction. Increased mucus production and bronchoconstriction (Choice B) are part of the physiological responses in asthma but do not directly cause acute episodes. Allergic reactions and hyperventilation (Choice C) are related to asthma triggers and responses but are not the direct causes of acute episodes. Airway narrowing and decreased lung capacity (Choice D) are consequences of inflammation and bronchospasm but do not explain the physiological response leading to acute asthma episodes.
A client admitted to the intensive care unit with syndrome of inappropriate antidiuretic hormone (SIADH) has developed osmotic demyelination. Which intervention should the nurse implement first?
- A. Patch one eye.
- B. Reorient often.
- C. Range of motion.
- D. Evaluate swallow
Correct Answer: B
Rationale: Frequent reorientation is crucial for clients with neurological impairments from osmotic demyelination to prevent confusion and assist with orientation. It helps maintain a proper sense of time, place, and person, reducing disorientation. Patching one eye (Choice A) is not a priority intervention for osmotic demyelination and does not address the immediate need for reorientation. Range of motion exercises (Choice C) may be important for overall care, but reorientation takes precedence due to its impact on neurological functioning. Evaluating swallow (Choice D) is not the primary intervention needed for osmotic demyelination; it is essential but not the first priority.
When admitting a client diagnosed with active tuberculosis to isolation, which infection control measures should the nurse implement?
- A. Negative pressure environment
- B. Contact precautions
- C. Droplet precautions
- D. Protective environment
Correct Answer: A
Rationale: The correct answer is A: Negative pressure environment. Tuberculosis is transmitted through airborne particles, so a negative pressure room is essential to prevent the spread of the bacteria. Choice B, contact precautions, are used for infections spread by direct or indirect contact, not for tuberculosis. Choice C, droplet precautions, are for infections transmitted through respiratory droplets, not airborne particles like tuberculosis. Choice D, protective environment, is used for protecting immunocompromised patients from outside pathogens, not for preventing the spread of tuberculosis.
A client is admitted with acute low back pain. What action should the nurse implement to promote comfort?
- A. Ambulate with a walker for upper body support
- B. Perform abdominal curls to stretch the back muscles
- C. Position in semi-Fowler's with the knees flexed
- D. Encourage straight leg raises while lying supine
Correct Answer: C
Rationale: Positioning the client in semi-Fowler's with the knees flexed is the most appropriate action to promote comfort in a client with acute low back pain. This position helps alleviate low back pain by reducing the pressure on the spine and supporting its natural curvature. Ambulating with a walker could strain the back, performing abdominal curls may exacerbate the pain, and straight leg raises while lying supine could cause further discomfort. Therefore, only positioning the client in semi-Fowler's with the knees flexed is the correct choice for promoting comfort in this scenario.