Nokea
The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement prior to the procedure?
- A. Determine if the client has claustrophobia.
- B. Obtain a signed informed consent form.
- C. Determine if the client is allergic to egg yolks.
- D. Start an intravenous line in both hands.
Correct Answer: A
Rationale: MRI involves a confined space, so assessing for claustrophobia (A) ensures patient comfort and safety. Consent (B) is required but secondary, egg yolk allergy (C) is irrelevant, and bilateral IVs (D) are unnecessary.
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The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
- A. The client will regain as much neurological function as possible.
- B. The client will have no short-term memory loss.
- C. The client will have improved renal function.
- D. The client will apply hydrocortisone cream daily.
Correct Answer: A
Rationale: The goal for encephalitis is to maximize neurological recovery (A), as inflammation may cause deficits. No memory loss (B) is unrealistic, renal function (C) is unrelated, and hydrocortisone cream (D) is not indicated.
The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
- A. Assess the client’s neurological status every hour.
- B. Monitor the client’s heart rhythm via telemetry.
- C. Administer an anticonvulsant medication by intravenous push.
- D. Prepare to administer a glucocorticosteroid orally.
Correct Answer: C
Rationale: Status epilepticus is a life-threatening continuous seizure requiring immediate IV anticonvulsants (C), such as lorazepam or phenytoin, to stop the seizure. Neurological assessment (A) and telemetry (B) are supportive, and glucocorticoids (D) are not indicated.
The client being monitored while receiving tissue plasminogen activator (tPA) following an ischemic stroke opens both eyes spontaneously, mumbles inappropriate words in response to orientation questions, has no ability to move any extremities, and has decerebrate posturing in response to nailbed pressure. Based on the chart illustrated, what is the client’s Glasgow Coma Scale (GCS) score?
- A. 9 GCS score
Correct Answer: 9
Rationale: Spontaneous eye opening is scored as 4; the best verbal response of inappropriate words is scored as 3, and the best motor response of decerebrate posturing is scored as 2.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
Which client behavior during a seizure requires immediate intervention?
- A. Lip smacking
- B. Rhythmic limb jerking
- C. Incontinence
- D. Tongue biting
Correct Answer: D
Rationale: Tongue biting during a seizure can cause airway obstruction or severe injury, requiring immediate intervention to protect the airway.