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The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
- A. Purposeless movement in response to painful stimuli.
- B. Flaccid paralysis in all four extremities.
- C. Decerebrate posturing when painful stimuli are applied.
- D. Pupils that are 6 mm in size and nonreactive on painful stimuli.
Correct Answer: A
Rationale: Purposeless movement (A) indicates a higher level of brain function compared to decorticate posturing, suggesting improvement. Flaccid paralysis (B) or decerebrate posturing (C) indicates worsening, and nonreactive pupils (D) suggest severe brain damage.
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Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis?
- A. History of a cold or gastrointestinal upset in the last month.
- B. Complaints of double vision and drooping eyelids.
- C. Fatigue, progressive muscle weakness, and twitching.
- D. Loss of sensation below the level of the umbilicus.
Correct Answer: C
Rationale: ALS presents with fatigue, progressive muscle weakness, and fasciculations (twitching, C). Recent illness (A) is nonspecific, double vision/ptosis (B) suggests myasthenia gravis, and sensory loss (D) is not typical of ALS.
The client diagnosed with substance abuse is being discharged from a drug and alcohol rehabilitation facility. Which information should the nurse teach the client?
- A. Do not go anyplace where you can be tempted to use again.'
- B. It is important that you attend a 12-step meeting regularly.'
- C. Now that you are clean, your family will be willing to see you again.'
- D. You should explain to all your coworkers what has happened.'
Correct Answer: B
Rationale: 12-step programs (B) provide ongoing support and accountability, critical for maintaining sobriety. Avoiding temptation (A) is vague, family reconciliation (C) is not guaranteed, and disclosing to coworkers (D) may breach privacy.
The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?
- A. The client has purposeful movement with painful stimuli.
- B. The client has assumed adduction of the upper extremities.
- C. The client is aimlessly thrashing in the bed.
- D. The client has become flaccid and does not respond to stimuli.
Correct Answer: D
Rationale: Flaccid paralysis and unresponsiveness (D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (A) or thrashing (C) suggest improvement, and adduction (B) is not a standard indicator.
The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of 'impaired nutrition.' Which nursing intervention would be included in the plan of care?
- A. Consult the occupational therapist for adaptive appliances for eating.
- B. Request a low-fat, low-sodium diet from the dietary department.
- C. Provide three (3) meals per day that include nuts and whole-grain breads.
- D. Offer six (6) meals per day with a soft consistency.
Correct Answer: A
Rationale: PD can impair fine motor skills, making eating difficult. Consulting an occupational therapist (A) for adaptive appliances supports nutritional intake. Low-fat diets (B) are not specific, nuts/breads (C) may be hard to chew, and six soft meals (D) may not address motor issues.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.