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If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?
- A. Administer another dose of the nonopioid analgesic immediately.
- B. Rearrange medication times so that the client receives pain medication hourly.
- C. Consult the physician about ordering an opioid analgesic.
- D. Use a nondrug intervention such as listening to a guided imagery tape.
Correct Answer: D
Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.
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When the nurse monitors the client's neurologic status, which finding is most suggestive that the client's intracranial pressure is increasing?
- A. Widening pulse pressure
- B. Increased respiratory rate
- C. Elevated temperature
- D. Decreased level of consciousness
Correct Answer: A
Rationale: Widening pulse pressure is a hallmark sign of increasing intracranial pressure, often accompanied by bradycardia (Cushing's triad).
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
Which nursing intervention is best during the confusedness?
- A. Reading a newspaper or magazine to the client
- B. Informing the client that confusion is temporary
- C. Withholding verbal communication temporarily
- D. Reorienting the client to place and situation
Correct Answer: D
Rationale: Reorienting the client to place and situation reduces confusion and promotes safety post-craniotomy.
Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- A. Potential for injury.
- B. Powerlessness.
- C. Disturbed thought processes.
- D. Sexual dysfunction.
Correct Answer: B
Rationale: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (B). Injury (A) is physical, disturbed thought processes (C) relate to cognition, and sexual dysfunction (D) is not directly linked to aphasia.