Nokea
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
- A. Discuss how to correctly remove the insertion pins.
- B. Instruct the client to report reddened or irritated skin areas.
- C. Inform the client that the vest liner cannot be changed.
- D. Encourage the client to remain in the recliner as much as possible.
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (B) prevents pressure ulcers. Removing pins (A) is done by providers, the vest liner can be changed (C), and prolonged recliner use (D) risks immobility complications.
You may also like to solve these questions
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.
The client who has expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful?
- A. Position the client facing the nurse
- B. Enunciate directions very slowly
- C. Use gestures and body language
- D. Ask the client to point to needed objects
Correct Answer: D
Rationale: Having the client face the nurse will not aid the client in expressing his or her needs. The nurse’s slow enunciation of directions will not aid the client in expressing his or her needs. Using gestures and body language will not aid the client in expressing his or her needs. Asking the client to point to needed objects would be most helpful when the client is having difficulty communicating with the nurse.
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.
The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke?
- A. A 92-year-old client who is an alcoholic.
- B. A 54-year-old client diagnosed with hepatitis.
- C. A 60-year-old client who has a Greenfield filter.
- D. A 68-year-old client with chronic atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation (D) increases stroke risk due to clot formation. Age (A) is a factor but less specific, hepatitis (B) is unrelated, and Greenfield filters (C) prevent pulmonary embolism, not stroke.
Which client statement indicates a need for further teaching about meningitis precautions?
- A. I'll wear a mask when visitors come.'
- B. My family should wash their hands frequently.'
- C. I can share my water bottle with my spouse.'
- D. I'll stay in my room to avoid spreading germs.'
Correct Answer: C
Rationale: Sharing a water bottle can transmit meningitis, indicating a misunderstanding of droplet precaution protocols.