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The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as 'high risk for immobility complications.' Which intervention would be included in the plan of care?
- A. Position the client with the head of the bed elevated at intervals.
- B. Perform active range-of-motion (ROM) exercises every four (4) hours.
- C. Turn the client every shift and massage bony prominences.
- D. Explain all procedures to the client before performing them.
Correct Answer: A
Rationale: For a comatose patient, preventing immobility complications like pressure ulcers and contractures is key. Elevating the HOB at intervals (A) promotes circulation and reduces pressure. Active ROM (B) is not possible in coma, turning every shift (C) is too infrequent, and explaining procedures (D) is less relevant.
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Which assessment data should the nurse expect to observe for the client diagnosed with Parkinson's disease?
- A. Ascending paralysis and pain.
- B. Masklike facies and pill rolling.
- C. Diplopia and ptosis.
- D. Dysphagia and dysarthria.
Correct Answer: B
Rationale: Masklike facies and pill-rolling tremors (B) are hallmark Parkinson’s signs due to dopamine deficiency. Paralysis/pain (A) suggest Guillain-Barré, diplopia/ptosis (C) indicate myasthenia gravis, and dysphagia/dysarthria (D) are later symptoms.
The client is prescribed a loading dose of phenytoin of 15 mg/kg IV for seizure activity, then 100 mg IV tid. The client weighs 198 lb. What dose in mg should the nurse administer for the loading dose of phenytoin?
- A. 1350 mg IV
Correct Answer: 1350
Rationale: 198 lb = 90 kg; (198 ÷ 2.2 = 90 kg; 90 x 15 = 1350) The nurse should administer 1350 mg phenytoin (Dilantin).
The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, 'I don’t know what you mean. What are auras?' Which statement by the nurse would be the best response?
- A. Some people have a warning that the seizure is about to start.'
- B. Auras occur when you are physically and psychologically exhausted.'
- C. You’re concerned that you do not have auras before your seizures?'
- D. Auras usually cause you to be sleepy after you have a seizure.'
Correct Answer: A
Rationale: Auras are sensory warnings preceding a seizure (A), and this response accurately educates the client. Other options misdefine auras (B, D) or fail to address the question (C).
If the client begins to have a seizure after the EEG, which action should the nurse take first?
- A. Administer oxygen by nasal cannula.
- B. Measure the blood pressure and pulse.
- C. Check the client's pupils.
- D. Place the client in a side-lying position.
Correct Answer: D
Rationale: Placing the client in a side-lying position prevents aspiration and maintains airway patency during a seizure.