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The client is withdrawing from a heroin addiction. Which interventions should the nurse implement? Select all that apply.
- A. Initiate seizure precautions.
- B. Check vital signs every eight (8) hours.
- C. Place the client in a quiet, calm atmosphere.
- D. Have a consent form signed for HIV testing.
- E. Provide the client with sterile needles.
Correct Answer: C
Rationale: Heroin withdrawal causes discomfort but not seizures, so seizure precautions (A) are unnecessary. Vital signs every 8 hours (B) is too infrequent; every 4 hours is standard. A quiet, calm atmosphere (C) reduces stimulation. HIV testing (D) requires consent but isn’t withdrawal-specific, and sterile needles (E) are inappropriate.
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Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured left leg?
- A. Assessing the neurological status.
- B. Immobilizing the fractured leg.
- C. Monitoring the client's output.
- D. Starting an 18-gauge saline lock.
Correct Answer: A
Rationale: Trauma patients require a primary survey, prioritizing neurological status (A) to detect head injuries, which are life-threatening. Immobilizing the leg (B), monitoring output (C), and IV access (D) follow.
The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply.
- A. Nuchal rigidity
- B. Severe headache
- C. Pill-rolling tremor
- D. Photophobia
- E. Lethargy
Correct Answer: A,B,D,E
Rationale: Irritation of the meninges causes nuchal rigidity (stiff neck). Irritation of the meninges causes severe headache. Pill-rolling tremors are associated with PD. Irritation of the meninges causes photophobia (light irritates the eyes). Lethargy, pathological state of sleepiness or unresponsiveness, indicates a decreased level of consciousness which is associated with meningitis.
The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP?
- A. Purpuric lesions on the face.
- B. Complaints of light hurting the eyes.
- C. Dull, aching, frontal headache.
- D. Not remembering the day of the week.
Correct Answer: A
Rationale: Purpuric lesions (A) indicate possible meningococcemia, a life-threatening complication requiring immediate HCP notification. Photophobia (B), headache (C), and confusion (D) are expected but less urgent.
When changing the client's position postoperatively, which nursing action is best?
- A. Raise the client with a mechanical lift.
- B. Logroll the client from side to side.
- C. Have the client flex the knees and lift.
- D. Pull the client's arms and then the legs.
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.