Nokea
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
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The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client’s history of the injury should the nurse associate with the TBI? Select all that apply.
- A. The client has had no episodes of vomiting after the accident.
- B. The client remembers events before and right after the accident.
- C. The client has had headache and dizziness daily since the accident.
- D. The client has difficulty concentrating and focusing while at work.
- E. The client lost consciousness momentarily at the time of the injury.
Correct Answer: C,D,E
Rationale: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
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.
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.
For a client with Guillain-Barré syndrome, which complication should the nurse monitor most closely?
- A. Urinary incontinence
- B. Deep vein thrombosis
- C. Hypertension
- D. Hypoglycemia
Correct Answer: B
Rationale: Deep vein thrombosis is a significant risk in Guillain-Barré syndrome due to immobility from muscle weakness.
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor?
- A. Nervousness, metastasis to the lungs, and seizures.
- B. Headache, vomiting, and papilledema.
- C. Hypotension, tachycardia, and tachypnea.
- D. Abrupt loss of motor function, diarrhea, and changes in taste.
Correct Answer: B
Rationale: The classic triad for brain tumors is headache, vomiting, and papilledema (B), due to increased ICP. Other options include unrelated or less specific symptoms.