Nokea
In addition to routine vital signs, what should the nurse assess because the client had a lumbar laminectomy?
- A. Hand grasps
- B. Foot strength
- C. Ability to swallow
- D. Abdominal muscle strength
Correct Answer: B
Rationale: Lumbar laminectomy affects lower spine nerves; assessing foot strength evaluates neurological function in the legs. Hand grasps, swallowing, and abdominal strength are unrelated.
You may also like to solve these questions
An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the allergies listed below. Which of these allergies should all health care personnel be aware of?
- A. Shellfish
- B. Molds
- C. Balloons
- D. Perfumed soap
Correct Answer: C
Rationale: Allergy to balloons indicates a latex allergy. All personnel in contact with the child will need to be aware of this condition and use non-latex gloves.
The nurse is caring for a client with a chest tube. On the second postoperative day, the chest tube accidentally disconnects from the drainage tube. The first action the nurse should take is
- A. reconnect the tube
- B. raise the collection chamber above the client's chest
- C. call the health care provider
- D. clamp the chest tube
Correct Answer: D
Rationale: Immediate steps should be taken to prevent air from entering the chest cavity. Lung collapse may occur if air enters the chest cavity. Clamping the tube close to the client's chest is the first action to take, followed by health care provider notification.
A client with signs of increased intracranial pressure (ICP).
In planning care for a client with signs of increased intracranial pressure (ICP), the nurse would include which of the following?
- A. Encourage coughing and deep breathing to prevent pneumonia.
- B. Suction the airway every 2 hours to remove secretions.
- C. Position the client in the prone position to promote venous return.
- D. Determine cough reflex and ability to swallow prior to administering PO fluids.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) increases intracranial pressure (2) increases intracranial pressure (3) head of the bed should be elevated 15 to 30° to promote venous drainage (4) correct-assessment, cough or gag reflex and the swallowing reflex may be affected by the increased pressure; increases the incidence of aspiration
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do
The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.