Nokea
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
- A. Administer a nonnarcotic analgesic.
- B. Prepare for STAT magnetic resonance imaging (MRI).
- C. Start an intravenous infusion with D5W at 100 mL/hr.
- D. Complete a neurological assessment.
Correct Answer: D
Rationale: A severe headache in a stroke patient may indicate complications like hemorrhagic transformation or increased intracranial pressure. A neurological assessment (D) is the first step to evaluate the cause and guide further actions. Analgesics (A) may mask symptoms, MRI (B) requires assessment first, and IV fluids (C) are not urgent.
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The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest 'Lou Gehrig’s' disease. Which is the nurse’s most appropriate response?
- A. “Muscle weakness can occur from working too much. Avoid thinking the worst.”
- B. “Tell me what has you thinking that you might have Lou Gehrig’s disease.”
- C. “Have you been having trouble remembering things along with this weakness?”
- D. “That is a good question. We will be doing tests to figure out what is going on.”
Correct Answer: B
Rationale: There is no information that the client is working too much. Telling the client to avoid thinking the worst belittles the client’s concern. This is the most appropriate response because it focuses on the client’s concern, encourages verbalization, and solicits more information. ALS (Lou Gehrig’s disease) is a degenerative disease that affects the motor system and does not have a dementia component; thus, a question about memory is inappropriate. This response does not take the client seriously and does not address the client’s concern.
The intensive care nurse is caring for the client who has had intracranial surgery. Which interventions should the nurse implement? Select all that apply.
- A. Assess for deep vein thrombosis.
- B. Administer intravenous anticoagulant.
- C. Monitor intake and output strictly.
- D. Apply warm compresses to the eyes.
- E. Perform passive range-of-motion exercises.
Correct Answer: A,C,E
Rationale: Assessing DVT (A), monitoring intake/output (C), and passive ROM (E) prevent complications. Anticoagulants (B) increase bleeding risk, and warm compresses (D) are not indicated.
The client underwent a lumbar laminectomy with spinal fusion 12 hours earlier. Which nursing assessment finding indicates that the client has a leakage of CSF?
- A. Backache not relieved by narcotic analgesics
- B. 50 mL of serosanguineous fluid in the bulb drain
- C. Clear fluid drainage noted on the surgical dressing
- D. Sudden spike in temperature to 101.3°F (38.5°C)
Correct Answer: C
Rationale: Unrelieved back pain may be associated with another complication, not CSF leakage. A severe headache, rather than back pain, may be associated with CSF leakage. 50 mL of serosanguineous fluid in the bulb drain is a normal finding. Clear drainage on the surgical dressing is indicative of a CSF leak. The temperature elevation could indicate an infection.
If the client begins to have a seizure after the EEG, which action should the nurse take first?
- A. Administer oxygen by nasal cannula.
- B. Measure the blood pressure and pulse.
- C. Check the client's pupils.
- D. Place the client in a side-lying position.
Correct Answer: D
Rationale: Placing the client in a side-lying position prevents aspiration and maintains airway patency during a seizure.
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client’s spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?
- A. “Plasmapheresis removes excess fluid from the bloodstream.”
- B. “Plasmapheresis will increase the protein levels in the blood.”
- C. “Plasmapheresis removes circulating antibodies from the blood.”
- D. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”
Correct Answer: C
Rationale: Aquapheresis or dialysis, not plasmapheresis, will remove excess fluid from the blood. Plasmapheresis does not increase protein levels in the blood. Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client. Plasmapheresis does not involve infusing lipoproteins.