Nokea
The client diagnosed with a brain abscess is experiencing a tonic-clonic seizure. Which interventions should the nurse implement? Rank in order of performance.
- A. Assess the client’s mouth.
- B. Loosen restrictive clothing.
- C. Administer phenytoin IVP.
- D. Turn the client to the side.
- E. Protect the client’s head from injury.
Correct Answer: E,B,C,D,A
Rationale: 1. Protect the client’s head (E): Prevents injury during convulsions. 2. Loosen restrictive clothing (B): Ensures airway and circulation. 3. Turn to the side (D): Prevents aspiration post-seizure. 4. Administer phenytoin (C): Stops the seizure after safety is ensured. 5. Assess the mouth (A): Done post-seizure to check for injury.
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Which measure for preventing impaired skin integrity is appropriate to add to the care plan at this time?
- A. Use an air-fluidized (Clinitron) bed.
- B. Change the client's position every 2 hours.
- C. Rub any reddened areas every 2 hours.
- D. Provide daily treatment in a hyperbaric oxygen chamber.
Correct Answer: B
Rationale: Changing position every 2 hours prevents pressure ulcers in clients with MS who have weakness and numbness.
The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke?
- A. A 92-year-old client who is an alcoholic.
- B. A 54-year-old client diagnosed with hepatitis.
- C. A 60-year-old client who has a Greenfield filter.
- D. A 68-year-old client with chronic atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation (D) increases stroke risk due to clot formation. Age (A) is a factor but less specific, hepatitis (B) is unrelated, and Greenfield filters (C) prevent pulmonary embolism, not stroke.
Which discharge teaching is essential for a client with a spinal cord injury to prevent respiratory complications?
- A. Perform deep breathing exercises daily.
- B. Avoid outdoor activities.
- C. Limit fluid intake to reduce secretions.
- D. Sleep in a prone position.
Correct Answer: A
Rationale: Deep breathing exercises help prevent atelectasis and pneumonia in clients with spinal cord injuries.
Which preoperative assessment is most important to document as a basis for postoperative comparison?
- A. Motor strength in all extremities
- B. Sodium and potassium laboratory values
- C. Pulses in lower extremities
- D. Glucometer blood glucose levels
Correct Answer: A
Rationale: Motor strength assessment provides a baseline to detect postoperative neurological deficits from brain tumor surgery.
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?
- A. Assess lung sounds.
- B. Assess the six cardinal fields of gaze.
- C. Assess apical pulse.
- D. Assess level of consciousness.
Correct Answer: D
Rationale: Level of consciousness (D) is the priority assessment in meningitis, as it indicates neurological status and potential complications like increased ICP. Lung sounds (A), eye movements (B), and pulse (C) are secondary.