Nokea
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
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The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has 'started using again.' Which action should the nurse implement?
- A. Tell Client A the nurse cannot discuss Client B with him.
- B. Find out how Client A got this information.
- C. Inform the HCP that Client B is using again.
- D. Get in touch with Client B and have the client come to the clinic.
Correct Answer: D
Rationale: Allegations of relapse require direct assessment. Contacting Client B (D) allows the nurse to evaluate the situation respectfully. Discussing Client B with Client A (A) or probing Client A (B) breaches confidentiality, and informing the HCP (C) is premature without verification.
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
- A. A 55-year-old African American male.
- B. An 84-year-old Japanese female.
- C. A 67-year-old Caucasian male.
- D. A 39-year-old pregnant female.
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
Which medication should the nurse administer first during a prolonged seizure?
- A. Phenytoin (Dilantin) IV
- B. Lorazepam (Ativan) IV
- C. Levetiracetam (Keppra) oral
- D. Carbamazepine (Tegretol) oral
Correct Answer: B
Rationale: Lorazepam IV is the first-line treatment for status epilepticus to rapidly stop seizure activity.
The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.