Nokea
Of the following nursing observations, which is most important to discuss the client's condition?
- A. The client has a chronic cough.
- B. The client is becoming jittery.
- C. The client's skin is warm and clammy.
- D. The client develops diarrhea.
Correct Answer: A
Rationale: A chronic cough increases intrathoracic pressure, which can elevate intracranial pressure and risk aneurysm rupture.
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The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
When the nurse performs a physical assessment, which finding is most indicative of the client's disorder?
- A. Quivering eye movement
- B. Muscle spasms in the lower extremities
- C. Loss of motor function on the affected side
- D. Unilateral facial paralysis
Correct Answer: D
Rationale: Unilateral facial paralysis is the hallmark sign of Bell's palsy, caused by inflammation of cranial nerve VII.
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
- A. Discuss how to correctly remove the insertion pins.
- B. Instruct the client to report reddened or irritated skin areas.
- C. Inform the client that the vest liner cannot be changed.
- D. Encourage the client to remain in the recliner as much as possible.
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (B) prevents pressure ulcers. Removing pins (A) is done by providers, the vest liner can be changed (C), and prolonged recliner use (D) risks immobility complications.
When documenting a seizure, which information is most important to include initially?
- A. The time the seizure started
- B. The duration of the seizure
- C. The client's mood just before the seizure
- D. The client's comments after the seizure
Correct Answer: A
Rationale: Documenting the time the seizure started is critical for tracking seizure patterns and guiding treatment.
The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care?
- A. Administer antibiotics.
- B. Obtain a sputum culture.
- C. Monitor the pulse oximeter.
- D. Assess intake and output.
Correct Answer: A
Rationale: Bacterial meningitis requires prompt antibiotic administration (A) as a collaborative intervention with the provider. Sputum culture (B) is not relevant, pulse oximetry (C) is supportive, and intake/output (D) is a nursing action.