Nokea
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
- A. The client will return to work within six (6) months.
- B. The client is able to focus and stay on task for 10 minutes.
- C. The client will be able to dress self without assistance.
- D. The client will regain bowel and bladder control.
Correct Answer: B
Rationale: Cognitive deficits post-TBI may limit complex tasks. Focusing for 10 minutes (B) is a realistic short-term goal to build cognitive endurance. Returning to work (A) may be unrealistic within 6 months, dressing independently (C) requires motor and cognitive skills, and bowel/bladder control (D) may be affected by physical deficits.
You may also like to solve these questions
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, 'Why can’t I control these tremors?' Which is the nurse’s best response?
- A. You can control the tremors when you learn to concentrate and focus on the cause.'
- B. The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.'
- C. You have too much acetylcholine in your brain causing the tremors but they will get better with time.'
- D. You are concerned about the tremors? If you want to talk I would like to hear how you feel.'
Correct Answer: B
Rationale: Parkinson’s tremors result from dopamine deficiency (B), and medications like levodopa help. Concentration (A) doesn’t control tremors, acetylcholine imbalance (C) is partial and not time-resolving, and reflection (D) doesn’t answer the question.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.
The client has had recurrent episodes of low back pain. Which statement indicates that the client has incorporated positive lifestyle changes to decrease the incidence of future back problems?
- A. “I stoop and avoid bending and twisting when lifting objects.”
- B. “I can walk farther if I wear my old comfortable shoes.”
- C. “I can walk only on weekends but walk 5 miles each day.”
- D. “I sit for 2 to 3 hours with my legs elevated for pain control.”
Correct Answer: A
Rationale: Stooping and avoiding bending and twisting motions when lifting objects lessen the likelihood of injury. The client should wear supportive shoes. The client should include regular daily exercise as a program (not excessive walking over 2 days on the weekend). Clients should avoid prolonged sitting or standing.
What should the nurse warn a client with multiple sclerosis to avoid?
- A. Hot weather
- B. Wet climates
- C. Your diet
- D. Cold temperatures
Correct Answer: A
Rationale: Hot weather can exacerbate MS symptoms by increasing body temperature, which impairs nerve conduction.