Nokea
The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?
- A. Do you have trouble hearing?'
- B. Are you allergic to any type of dairy products?'
- C. Have you eaten anything in the last eight (8) hours?'
- D. Are you uncomfortable in closed spaces?'
Correct Answer: D
Rationale: MRI scans require lying still in a confined space, so assessing for claustrophobia (D) is critical to ensure patient safety and comfort. Hearing issues (A), dairy allergies (B), and recent eating (C) are not relevant to MRI preparation.
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The client is diagnosed with ALS. Which client problem would be most appropriate for this client?
- A. Disuse syndrome.
- B. Altered body image.
- C. Fluid and electrolyte imbalance.
- D. Alteration in pain.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness, leading to disuse syndrome (A) from immobility. Body image (B) is secondary, fluid/electrolyte issues (C) are not primary, and pain (D) is less common.
Which intervention is priority for a client with AIDS dementia complex experiencing agitation?
- A. Administer a sedative as prescribed.
- B. Provide a quiet, low-stimulus environment.
- C. Restrain the client to prevent injury.
- D. Encourage group activities to distract the client.
Correct Answer: B
Rationale: A quiet, low-stimulus environment reduces agitation in clients with AIDS dementia complex by minimizing sensory overload.
The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first?
- A. Set the ventilator to hyperventilate the client in preparation for suctioning.
- B. Assess the client’s lung sounds and check for peripheral cyanosis.
- C. Turn the client to the side to allow the secretions to drain from the mouth.
- D. Suction the client using the in-line suction, wait 30 seconds, and repeat.
Correct Answer: C
Rationale: Pooled secretions risk airway obstruction. Turning to the side (C) clears the airway safely without increasing ICP. Hyperventilation (A) and suctioning (D) may raise ICP, and assessment (B) delays intervention.
When the nurse observes that the client has difficulty swallowing the capsule of medication, which action is best to take?
- A. Soak the capsule in water until soft.
- B. Tell the client to chew the capsule.
- C. Moisten the capsule in the client's mouth.
- D. Offer water before giving the capsule.
Correct Answer: D
Rationale: Offering water before giving the capsule aids swallowing without altering the medication's integrity.
Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
- A. A blood glucose level of 480 mg/dL.
- B. A right-sided carotid bruit.
- C. A blood pressure (BP) of 220/120 mm Hg.
- D. The presence of bronchogenic carcinoma.
Correct Answer: C
Rationale: Severe hypertension (BP 220/120 mm Hg, C) is a major risk factor for hemorrhagic stroke due to vessel rupture. High blood glucose (A) is more linked to ischemic stroke, a carotid bruit (B) indicates atherosclerosis, and bronchogenic carcinoma (D) is unrelated.