Nokea
On the basis of the factors that cause the client to experience paroxysmal pain, which intervention is most appropriate to include in this client's care plan?
- A. Direct a fan toward the client's face.
- B. Avoid care that involves touching the client's face.
- C. Apply ice packs to the client's face.
- D. Apply warm facial compresses for pain.
Correct Answer: B
Rationale: Avoiding facial touch minimizes triggering paroxysmal pain in trigeminal neuralgia, which is sensitive to tactile stimuli.
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After receiving report, the nurse working on the step-down neurological unit begins care for four clients. Prioritize the order in which the nurse should assess the four clients.
- A. 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering
- B. 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP
- C. 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation
- D. 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse.
Correct Answer: C,A,B,D
Rationale: The 24-year-old who had been unconscious at the scene of an MVA and is being admitted from the ED for observation. The nurse should assess the newly admitted client first to determine whether there are changes in level of consciousness and any early signs of increased ICP. The 78-year-old who underwent evacuation of a chronic subdural hematoma 24 hours earlier and is recovering. This client should be assessed next because the client is postoperative day 1, but stable. The 30-year-old who was diagnosed with viral meningitis 2 days earlier and wants to talk with the HCP. This client has a self-limiting condition and likely wants to be discharged; thus, he or she should be assessed third. The 40-year-old with Guillain-Barré who is currently receiving a third bedside plasmapheresis treatment being administered by another nurse. This client can be assessed last because another nurse is in the room with the client administering the plasmapheresis treatment.
Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
Which clinical manifestation is the educator most likely to include as the initial sign of Parkinson's disease?
- A. Muscle rigidity
- B. Muscle tremors
- C. Muscle weakness
- D. Muscle deterioration
Correct Answer: B
Rationale: Muscle tremors, particularly resting tremors, are often the initial sign of Parkinson's disease.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?
- A. Awaken the client every two (2) hours.
- B. Monitor for increased intracranial pressure (ICP).
- C. Observe frequently for hypervigilance.
- D. Offer the client food every three (3) to four (4) hours.
Correct Answer: A
Rationale: For a mild concussion, monitoring for worsening neurological status is key. Awakening every 2 hours (A) allows assessment for altered consciousness. Monitoring ICP (B) is complex and not feasible at home, hypervigilance (C) is not typical, and frequent feeding (D) is unnecessary.
Which type of precautions should the nurse implement for the client diagnosed with septic meningitis?
- A. Standard Precautions.
- B. Airborne Precautions.
- C. Contact Precautions.
- D. Droplet Precautions.
Correct Answer: D
Rationale: Meningococcal meningitis is transmitted via respiratory droplets, requiring Droplet Precautions (D) in addition to Standard Precautions. Airborne (B) and Contact (C) are not indicated.