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The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first?
- A. Elevate the head of the bed 30 degrees.
- B. Administer oxygen via nasal cannula.
- C. Assess the client’s lung sounds.
- D. Obtain a pulse oximeter reading.
Correct Answer: B
Rationale: Dyspnea in ALS indicates respiratory distress. Administering oxygen (B) addresses hypoxia immediately. Elevating HOB (A), assessing lung sounds (C), and pulse oximetry (D) follow to support respiratory status.
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Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
- A. Observe the client swallowing for possible aspiration.
- B. Position the client in a semi-Fowler's position when sleeping.
- C. Place a suction setup at the client's bedside during meals.
- D. Refer the client to an occupational therapist for evaluation.
Correct Answer: D
Rationale: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A, C) are related to dysphagia, not agnosia, and semi-Fowler’s position (B) is not specific to agnosia management.
The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?
- A. A normal temperature will strengthen the client’s immune system.
- B. A hypothermic state may increase the client’s chance of survival.
- C. A normal temperature will decrease the Glasgow Coma Scale score.
- D. Hyperthermia increases the likelihood of a larger area of brain infarct.
Correct Answer: D
Rationale: A normal temperature does not strengthen the immune system. Although hypothermia may increase the client’s chance for survival, the question is asking for the rationale for bringing the temperature to a normal level. Hyperthermia, not a normal temperature, is associated with lower scores on the Glasgow Coma Scale. The nurse should initiate temperature reduction measures because a temperature elevation in the client poststroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
- A. A computed tomography (CT).
- B. Blood cultures times two (2).
- C. Electromyogram (EMG).
- D. Lumbar puncture (LP).
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (D) confirms the diagnosis via CSF analysis. CT (A) may precede LP, blood cultures (B) are supportive, and EMG (C) is unrelated.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?
- A. Awaken the client every two (2) hours.
- B. Monitor for increased intracranial pressure (ICP).
- C. Observe frequently for hypervigilance.
- D. Offer the client food every three (3) to four (4) hours.
Correct Answer: A
Rationale: For a mild concussion, monitoring for worsening neurological status is key. Awakening every 2 hours (A) allows assessment for altered consciousness. Monitoring ICP (B) is complex and not feasible at home, hypervigilance (C) is not typical, and frequent feeding (D) is unnecessary.