Nokea
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?
- A. Assess neurological status.
- B. Monitor pulse, respiration, and blood pressure.
- C. Initiate an intravenous access.
- D. Maintain an adequate airway.
Correct Answer: D
Rationale: Airway maintenance (D) is the highest priority in any critically ill patient, including those with head injuries, to ensure oxygenation. Neurological assessment (A), vital signs (B), and IV access (C) follow after securing the airway.
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When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.
- A. Avoid twisting or jerking the back.
- B. Wear a soft back brace at all times.
- C. Avoid sitting for long periods during the first week.
- D. Bend from the waist when picking up items from the floor.
- E. Monitor urine output for the first week.
- F. Report lower extremity color changes to the physician.
Correct Answer: A,C,F
Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.
When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?
- A. 1/4'' (0.6 cm)
- B. 1/2'' (1.3 cm)
- C. 1'' (2.5 cm)
- D. 2'' (5 cm)
Correct Answer: C
Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.
Which priority goal would the nurse identify for a client diagnosed with Parkinson’s Disease (PD)?
- A. The client will be able to maintain mobility and swallow without aspiration.
- B. The client will verbalize feelings about the diagnosis of Parkinson’s Disease.
- C. The client will understand the purpose of medications administered for PD.
- D. The client will have a home health agency for monitoring at home.
Correct Answer: A
Rationale: Maintaining mobility and safe swallowing (A) are priority goals in Parkinson’s to prevent falls and aspiration. Verbalizing feelings (B), understanding medications (C), and home health (D) are secondary.
Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse’s priority when receiving the client in the ED?
- A. Assessing the client using the Glasgow Coma Scale (GCS)
- B. Assessing the level of sensation in the client’s extremities
- C. Checking that the cervical collar was correctly placed by EMS
- D. Applying antiembolism hose to the client’s lower extremities
Correct Answer: C
Rationale: The nurse should determine the neurological status using the GCS, but this is not the priority. The nurse should assess sensation status at intervals to determine neurological injury progression, but this is not the priority. Maintaining the correct placement of the cervical collar will keep the client’s head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar is correctly placed will prevent further injury, it is priority. Applying antiembolism hose is an intervention to prevent thromboembolic complications, but this is not the priority.
The nurse writes the nursing diagnosis 'altered body temperature related to damaged temperature regulating mechanism' for a client with a head injury. Which would be the most appropriate goal?
- A. Administer acetaminophen (Tylenol) for elevated temperature.
- B. The client's temperature will remain less than 100°F.
- C. Maintain the hypothermia blanket at 99°F for 24 hours.
- D. The basal metabolic temperature will fluctuate no more than two (2) degrees.
Correct Answer: B
Rationale: The goal for altered body temperature is to maintain a normal range, such as less than 100°F (B). Administering medication (A) is an intervention, hypothermia blanket (C) is specific, and basal fluctuation (D) is vague.