Nokea
The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
- A. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes.
- B. The client diagnosed with Parkinson’s disease who fell during the night and is complaining of difficulty walking.
- C. The client diagnosed with a cerebrovascular accident whose vital signs are P 60, R 14, and BP 198/68.
- D. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
Correct Answer: A
Rationale: Aseptic meningitis with headache and photophobia (A) is a stable condition suitable for a new graduate, requiring basic symptom management. Parkinson’s with a fall (B) needs fall risk assessment, CVA with high BP (C) requires experienced intervention, and brain tumor with visual changes (D) suggests progression needing expertise.
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The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?
- A. A normal temperature will strengthen the client’s immune system.
- B. A hypothermic state may increase the client’s chance of survival.
- C. A normal temperature will decrease the Glasgow Coma Scale score.
- D. Hyperthermia increases the likelihood of a larger area of brain infarct.
Correct Answer: D
Rationale: A normal temperature does not strengthen the immune system. Although hypothermia may increase the client’s chance for survival, the question is asking for the rationale for bringing the temperature to a normal level. Hyperthermia, not a normal temperature, is associated with lower scores on the Glasgow Coma Scale. The nurse should initiate temperature reduction measures because a temperature elevation in the client poststroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.
The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
- A. Places a suction catheter in the client’s oral cavity to stimulate the cough reflex
- B. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough
- C. Cups the hands and percusses the client’s anterior, lateral, and posterior lung fields
- D. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen
- E. Elevates the head of the bed to a high Fowler’s position if the client is sitting in bed
Correct Answer: B,E
Rationale: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse’s hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
- A. This must be very hard for you. You’re feeling worthless?'
- B. You shouldn’t feel worthless—you are still alive.'
- C. Why do you feel worthless? You still have the use of your arms.'
- D. If you attended a work rehab program you wouldn’t feel worthless.'
Correct Answer: A
Rationale: Reflecting the client’s feelings (A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (B), challenge the client inappropriately (C), or assume solutions (D).
Which nursing action is priority for a client with a stroke experiencing unilateral neglect?
- A. Place objects on the unaffected side.
- B. Encourage bilateral arm exercises.
- C. Provide a mirror for self-awareness.
- D. Teach the client to scan the environment.
Correct Answer: D
Rationale: Teaching the client to scan the environment compensates for unilateral neglect, promoting safety and awareness.
The male client is admitted to the emergency department following a motorcycle accident. The client was not wearing a helmet and struck his head on the pavement. The nurse identifies the concept as impaired intracranial regulation. Which interventions should the emergency department nurse implement in the first five (5) minutes? Select all that apply.
- A. Stabilize the client’s neck and spine.
- B. Contact the organ procurement organization to speak with the family.
- C. Elevate the head of the bed to 70 degrees.
- D. Perform a Glasgow Coma Scale assessment.
- E. Ensure the client has a patent peripheral venous catheter in place.
- F. Check the client’s driver’s license to see if he will accept blood.
Correct Answer: A,D,E
Rationale: Stabilizing the cervical spine (A) prevents spinal injury, Glasgow Coma Scale (D) assesses neurological status, and IV access (E) prepares for interventions. Organ procurement (B) is premature, high HOB (C) risks perfusion, and checking for blood acceptance (F) is secondary.