Nokea
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
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When a client is injured during a seizure, which fact is most important to document on the incident (accident) report to reduce the risk of liability?
- A. The client was assigned to a licensed nurse.
- B. The signal cord was within the client's reach.
- C. The client's vital signs had been stable.
- D. The client was last observed reading.
Correct Answer: B
Rationale: Documenting that the signal cord was within reach indicates that safety measures were in place, reducing liability.
When planning a bowel retraining program for a client with a spinal cord injury, which nursing intervention is most appropriate?
- A. Administering a stool softener twice per week
- B. Encouraging the client to consume a high-fiber diet
- C. Having the client drink two glasses of water every morning
- D. Teaching the client to self-administer daily enemas
Correct Answer: B
Rationale: A high-fiber diet promotes regular bowel movements, which is essential for bowel retraining in spinal cord injury clients.
Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
- A. The client has flaccid paralysis.
- B. The client has purposeful movement.
- C. The client has decerebrate posturing with painful stimuli.
- D. The client does not move the extremities.
Correct Answer: B
Rationale: Purposeful movement (B) indicates improved brain function compared to decorticate posturing. Flaccid paralysis (A) or decerebrate posturing (C) suggest worsening, and no movement (D) is not an improvement.
Which intervention is most appropriate for a client with Bell's palsy experiencing eye dryness?
- A. Apply warm compresses to the affected eye.
- B. Administer oral antihistamines.
- C. Use artificial tears as prescribed.
- D. Cover the unaffected eye with a patch.
Correct Answer: C
Rationale: Artificial tears prevent corneal damage from eye dryness in Bell's palsy due to incomplete eye closure.
Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
- A. Complete neurovascular examinations every eight (8) hours.
- B. Maintain accurate intake and output at the end of each shift.
- C. Assess the client’s symptoms to determine if there is improvement.
- D. Administer intravenous fluids while assessing for overload.
Correct Answer: D
Rationale: IV fluids (D) support hydration in West Nile virus while monitoring for overload prevents complications. Neurovascular exams (A) are less relevant, intake/output (B) is routine, and symptom assessment (C) is nursing-driven.