Nokea
The client comes to the clinic for treatment of a dog bite. Which intervention should the clinic nurse implement first?
- A. Prepare the client for a series of rabies injections.
- B. Notify the local animal control shelter.
- C. Administer a tetanus toxoid in the deltoid.
- D. Determine if the animal has had its vaccinations.
Correct Answer: D
Rationale: Determining the animal’s vaccination status (D) is the first step to assess rabies risk, guiding further interventions. Rabies injections (A) are premature, animal control (B) is secondary, and tetanus (C) follows risk assessment.
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A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
- A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- B. Discuss the precipitating factors that caused the symptoms.
- C. Schedule for a STAT computed tomography (CT) scan of the head.
- D. Notify the speech pathologist for an emergency consult.
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply.
- A. Hemoglobin 9.5 g/dL and hematocrit is 31.8%
- B. Taking baclofen 15 mg 3 times per day
- C. Working 4 to 8 hours per week in the family business
- D. Stopped taking amitriptyline 8 weeks earlier
- E. Presence of a cardiac murmur at the tricuspid valve.
- F. Bilateral leg weakness noted when walking in room
Correct Answer: A,B,D,E,F
Rationale: The lower-than-normal Hgb and Hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen (Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. Working 4 to 8 hours per week is a limited number of hours and should not contribute to the client’s fatigue. The client has stopped amitriptyline (Elavil), an antidepressant, and may be clinically depressed. Fatigue is a major symptom of depression. A tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissues. The increased energy expenditure with ambulation can increase fatigue.
When implementing seizure precautions, which nursing action is most appropriate?
- A. Move the client to a room closer to the nurses' station.
- B. Serve the client's food in paper and plastic containers.
- C. Maintain the client's bed in the lowest position.
- D. Ensure that soft limb restraints are applied to upper extremities.
Correct Answer: C
Rationale: Maintaining the bed in the lowest position minimizes the risk of injury from falls during a seizure.
The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client’s history of the injury should the nurse associate with the TBI? Select all that apply.
- A. The client has had no episodes of vomiting after the accident.
- B. The client remembers events before and right after the accident.
- C. The client has had headache and dizziness daily since the accident.
- D. The client has difficulty concentrating and focusing while at work.
- E. The client lost consciousness momentarily at the time of the injury.
Correct Answer: C,D,E
Rationale: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
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.