Nokea
The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
You may also like to solve these questions
Which problem is the highest priority for the client diagnosed with West Nile virus?
- A. Alteration in body temperature.
- B. Altered tissue perfusion.
- C. Fluid volume excess.
- D. Altered skin integrity.
Correct Answer: A
Rationale: Fever (alteration in body temperature, A) is a primary symptom of West Nile virus, requiring priority management to prevent complications. Perfusion (B), fluid excess (C), and skin integrity (D) are less immediate.
During the immediate postoperative assessment, the nurse notices the dressing is moist. Which action is most appropriate to take first?
- A. Change the dressing.
- B. Reinforce the dressing.
- C. Remove the dressing.
- D. Document the findings.
Correct Answer: B
Rationale: Reinforcing the dressing controls minor drainage and maintains sterility while further assessment is conducted.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.
The nurse is working with clients and their families regarding substance abuse. Which statement is the scientific rationale for teaching the children new coping mechanisms?
- A. The child needs to realize that the parent will be changing behaviors.
- B. The child will need to point out to the parent when the parent is not coping.
- C. Children tend to mimic behaviors of parents when faced with similar situations.
- D. Children need to feel like they are a part of the parent’s recovery.
Correct Answer: C
Rationale: Children often mimic parental behaviors (C), including unhealthy coping mechanisms. Teaching new strategies helps break this cycle. Other options misrepresent the child’s role or focus.
The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.
- A. Monitor the pulse oximetry reading.
- B. Provide pureed foods six (6) times a day.
- C. Encourage coughing and deep breathing.
- D. Assess for autonomic dysreflexia.
- E. Administer intravenous corticosteroids.
Correct Answer: A,C,D
Rationale: Cervical SCI risks respiratory compromise and autonomic dysreflexia. Monitoring pulse oximetry (A) ensures oxygenation, coughing/deep breathing (C) prevents pneumonia, and assessing for autonomic dysreflexia (D) detects dangerous BP spikes. Pureed foods (B) are unnecessary without dysphagia, and corticosteroids (E) are not standard for acute SCI management.