Nokea
The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
- A. The elderly client who is experiencing a stroke in evolution.
- B. The client diagnosed with a transient ischemic attack 48 hours ago.
- C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
- D. The client with Alzheimer's disease who is wandering in the halls.
Correct Answer: A
Rationale: A stroke in evolution (A) is an acute, progressing condition requiring experienced monitoring. TIA (B) is stable, Guillain-Barré pain (C) is manageable, and wandering (D) needs supervision but is less acute.
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The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next?
- A. Carefully remove the driver from the car.
- B. Assess the client's pupils for reaction.
- C. Assess the client's airway.
- D. Attempt to wake the client up by shaking him.
Correct Answer: C
Rationale: After cervical spine stabilization, ensuring a patent airway (C) is the next priority to support oxygenation. Removing the driver (A) risks further injury, pupil assessment (B) is secondary, and shaking (D) could worsen spinal injury.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
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.
If the drug is administered every 3 to 4 hours, which nursing action is most appropriate at this time in response to the client's statement?
- A. Administer another dose of the nonopioid analgesic immediately.
- B. Rearrange medication times so that the client receives pain medication hourly.
- C. Consult the physician about ordering an opioid analgesic.
- D. Use a nondrug intervention such as listening to a guided imagery tape.
Correct Answer: D
Rationale: Using a nondrug intervention like guided imagery is appropriate since it's too early for another dose, and it avoids escalating to opioids prematurely.
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?
- A. Assess neurological status.
- B. Monitor pulse, respiration, and blood pressure.
- C. Initiate an intravenous access.
- D. Maintain an adequate airway.
Correct Answer: D
Rationale: Airway maintenance (D) is the highest priority in any critically ill patient, including those with head injuries, to ensure oxygenation. Neurological assessment (A), vital signs (B), and IV access (C) follow after securing the airway.