Nokea
The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first?
- A. Schedule a STAT Magnetic Resonance Imaging of the brain.
- B. Call a Code STROKE.
- C. Notify the health-care provider (HCP).
- D. Have the client swallow a glass of water.
Correct Answer: B
Rationale: Symptoms suggest an acute stroke, requiring immediate activation of a Code STROKE (B) to expedite diagnosis and treatment. MRI (A), notifying HCP (C), and swallowing tests (D) follow protocol activation.
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The client with a history of migraine headaches comes to the clinic and reports that a migraine is coming because the client is experiencing bright spots before the eyes. Which phase of migraine headaches is the client experiencing?
- A. Prodrome phase.
- B. Aura phase.
- C. Headache phase.
- D. Recovery phase.
Correct Answer: B
Rationale: Bright spots are visual auras (B), a sensory warning preceding migraines. Prodrome (A) involves mood changes, headache (C) is pain, and recovery (D) follows pain.
Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
- A. Poor skin turgor
- B. Decerebrate posturing
- C. Deep tendon reflexes
- D. Absent corneal reflex
- E. Dilated nonreactive pupils
- F. Dry mucous membranes
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.
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 statement by the female client indicates that the client understands factors that may precipitate seizure activity?
- A. It is all right for me to drink coffee for breakfast.'
- B. My menstrual cycle will not affect my seizure disorder.'
- C. I am going to take a class in stress management.'
- D. I should wear dark glasses when I am out in the sun.'
Correct Answer: C
Rationale: Stress can trigger seizures, so stress management classes (C) indicate understanding of seizure precipitants. Coffee (A) may increase seizure risk, menstrual cycles (B) can affect seizures due to hormonal changes, and dark glasses (D) are unrelated unless photosensitivity is a trigger.
Which is a common cognitive problem associated with Parkinson’s disease?
- A. Emotional lability.
- B. Depression.
- C. Memory deficits.
- D. Paranoia.
Correct Answer: B
Rationale: Depression (B) is a common cognitive/emotional problem in Parkinson’s due to dopamine dysregulation and chronic illness impact. Emotional lability (A) is less common, memory deficits (C) occur later, and paranoia (D) is not typical.