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If the client begins to have a seizure after the EEG, which action should the nurse take first?
- A. Administer oxygen by nasal cannula.
- B. Measure the blood pressure and pulse.
- C. Check the client's pupils.
- D. Place the client in a side-lying position.
Correct Answer: D
Rationale: Placing the client in a side-lying position prevents aspiration and maintains airway patency during a seizure.
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The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
- A. Tell the client to take any routine antiseizure medication prior to the EEG.
- B. Tell the client not to eat anything for eight (8) hours prior to the procedure.
- C. Instruct the client to stay awake for 24 hours prior to the EEG.
- D. Explain to the client that there will be some discomfort during the procedure.
Correct Answer: A
Rationale: Taking routine antiseizure medications (A) ensures therapeutic levels during the EEG, avoiding seizures that could skew results. Fasting (B) is unnecessary, sleep deprivation (C) may be used in specific cases but not routinely, and EEGs are painless (D).
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
- A. Obtain an informed consent from the client or significant other.
- B. Have the client empty the bladder prior to the procedure.
- C. Place the client in a side-lying position with the back arched.
- D. Instruct the client to breathe rapidly and deeply during the procedure.
- E. Explain to the client what to expect during the procedure.
Correct Answer: A,B,C,E
Rationale: Informed consent (A) is required, emptying the bladder (B) ensures comfort, side-lying with back arched (C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (D) is not advised.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
- A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours.
- B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
- C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.
- D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
Correct Answer: C
Rationale: A GCS score of 6 (C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (A) is standard for concussion, left-sided weakness (B) is concerning but less acute, and expressive aphasia (D) is stable.
The client, who had a stroke, follows the nurse’s instructions without problems, but an attempt to verbally respond to the nurse’s question was garbled. The nurse should identify that the client has which type of aphasia?
- A. Receptive aphasia
- B. Global aphasia
- C. Expressive aphasia
- D. Anomic aphasia
Correct Answer: C
Rationale: With receptive aphasia (Wernicke’s aphasia or fluent aphasia) the client would hear the voice but would be unable to comprehend the meaning of the message. Global aphasia is a combination of receptive and expressive aphasia. The client would have difficulty speaking and understanding words and would not be able to read or write. The nurse should identify that the client has expressive aphasia (Broca’s aphasia or non-fluent aphasia). The client is able to comprehend and responds appropriately. The client may attempt to speak but has difficulty communicating with the correct words. With anomic aphasia, the client would have word-finding difficulties; this client does not verbalize.