Nokea
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
- A. A subcutaneous anticoagulant.
- B. An intravenous osmotic diuretic.
- C. An oral anticonvulsant.
- D. An oral proton pump inhibitor.
Correct Answer: A
Rationale: Subcutaneous anticoagulants (A) increase bleeding risk in head injury patients, where intracranial hemorrhage is a concern, and should be questioned. Osmotic diuretics (B) reduce ICP, anticonvulsants (C) prevent seizures, and proton pump inhibitors (D) protect against stress ulcers.
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The client is admitted with a diagnosis of trigeminal neuralgia. Which assessment data would the nurse expect to find in this client?
- A. Joint pain of the neck and jaw.
- B. Unconscious grinding of the teeth during sleep.
- C. Sudden severe unilateral facial pain.
- D. Progressive loss of calcium in the nasal septum.
Correct Answer: C
Rationale: Trigeminal neuralgia causes sudden, severe, unilateral facial pain (C) due to irritation of the trigeminal nerve. Joint pain (A) is unrelated, teeth grinding (B) is bruxism, and calcium loss (D) is not a feature.
Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
Before discharge, the nurse instructs the client about administering subcutaneous injections and correctly explains the client should rotate injections between which two areas?
- A. Thighs and hips
- B. Forearms and hips
- C. Thighs and abdomen
- D. Abdomen and buttocks
Correct Answer: C
Rationale: Rotating injections between the thighs and abdomen minimizes tissue damage and ensures consistent absorption.
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
- A. Decerebrate posturing observed
- B. Decorticate posturing observed
- C. Positive Kernig’s sign observed
- D. Seizure activity observed
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
Which assessment finding is especially important to monitor when caring for a client with myasthenia gravis who is in crisis?
- A. Breathing
- B. Temperature
- C. Blood pressure
- D. Mental status
Correct Answer: A
Rationale: Respiratory muscle weakness in myasthenic crisis can lead to respiratory failure, making breathing the most critical assessment.