Nokea
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.
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Before the client undergoes the craniotomy, the nurse inserts a urinary catheter. How far should the catheter be inserted if the client is a male?
- A. 2'' to 4'' (5 to 10 cm)
- B. 4'' to 6'' (10 to 15 cm)
- C. 6'' to 8'' (15 to 20 cm)
- D. 8'' to 10'' (20 to 25.5 cm)
Correct Answer: D
Rationale: For a male, the urinary catheter should be inserted 8'' to 10'' to reach the bladder adequately.
The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?
- A. Explain that this procedure is not painful.
- B. Premedicate the client with a benzodiazepine drug.
- C. Instruct the client to shave all facial hair.
- D. Tell the client it will cause him to see 'floaters.'
Correct Answer: A
Rationale: Explaining that the EEG is painless (A) reduces anxiety. Benzodiazepines (B) are not routine, shaving (C) is unnecessary, and floaters (D) are not associated.
If the diagnosis is accurate, which assessment findings should the nurse document? Select all that apply.
- A. Photophobia
- B. A stiff neck
- C. Muscle weakness
- D. Diarrhea
- E. Vertigo
- F. Fever
Correct Answer: A,B,F
Rationale: Meningitis commonly presents with photophobia, stiff neck (nuchal rigidity), and fever due to inflammation of the meninges. Muscle weakness, diarrhea, and vertigo are not typically associated with meningitis.
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.
The client has been newly diagnosed with epilepsy. Which discharge instructions should be taught to the client? Select all that apply.
- A. Keep a record of seizure activity.
- B. Take tub baths only; do not take showers.
- C. Avoid over-the-counter medications.
- D. Have anticonvulsant medication serum levels checked regularly.
- E. Do not drive alone; have someone in the car.
Correct Answer: A,C,D,E
Rationale: Recording seizures (A) helps track treatment efficacy, avoiding OTC medications (C) prevents interactions, regular serum levels (D) ensure therapeutic dosing, and not driving alone (E) ensures safety. Tub baths (B) pose a drowning risk and are not advised.