Nokea
The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statements by the nurse will be helpful to the client? Select all that apply.
- A. “You need to continue to use contraceptives if you do not wish to have children.”
- B. “Unfortunately, your injury prevents you from being able to conceive children.”
- C. “Because feeling is affected, it is not likely that you will be able to deliver a baby.”
- D. “Sexual intercourse is generally prohibited because it can worsen your condition.”
- E. “You can engage in sexual intimacy, but you may not be able to feel an orgasm.”
Correct Answer: A,E
Rationale: Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. The client with an incomplete T6 SCI is able to get pregnant. Although the client may not feel the onset of labor, she may still be able to deliver the baby vaginally or via cesarean section. Sexual intercourse is allowable and would not worsen the client’s condition. The female may not be able to feel an orgasm. The client may not be able to feel an orgasm after an incomplete T6 SCI.
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The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
- A. Administer a nonnarcotic analgesic.
- B. Prepare for STAT magnetic resonance imaging (MRI).
- C. Start an intravenous infusion with D5W at 100 mL/hr.
- D. Complete a neurological assessment.
Correct Answer: D
Rationale: A severe headache in a stroke patient may indicate complications like hemorrhagic transformation or increased intracranial pressure. A neurological assessment (D) is the first step to evaluate the cause and guide further actions. Analgesics (A) may mask symptoms, MRI (B) requires assessment first, and IV fluids (C) are not urgent.
The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the NA to help the client with meals knowing that this problem may result in which client response?
- A. Tendency to fall to the contralateral side
- B. Eating food on only half of the plate
- C. Using the silverware inappropriately
- D. Choking when swallowing any liquids
Correct Answer: B
Rationale: Tendency to fall to the contralateral side would be a concern if the client were weak or paralyzed. Homonymous hemianopia (hemianopsia) is a visual field abnormality that results in blindness in half of the visual field in the same side of both eyes. It results from damage to the optic tract or occipital lobe. Using the silverware inappropriately is a concern if the client has agnosia. Choking when swallowing any liquids is a concern if the client has dysphagia.
The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?
- A. MRIs are loud but there will not be any invasive procedure done.'
- B. You’re scared. Tell me about what is scaring you.'
- C. This is the least thing to be scared about—there will be worse.'
- D. I can call the MRI tech to come and talk to you about the scan.'
Correct Answer: B
Rationale: Reflecting the client’s fear (B) encourages expression of concerns, fostering therapeutic communication. Other options provide information (A, D) or minimize feelings (C).
The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider’s order would have the highest priority?
- A. Administer an intravenous antibiotic.
- B. Obtain the client’s lunch tray.
- C. Provide a quiet, calm, and dark room.
- D. Weigh the client in hospital attire.
Correct Answer: A
Rationale: Prompt IV antibiotic administration (A) is critical in septic meningitis to combat infection and prevent complications. Lunch (B), environment (C), and weight (D) are secondary.
The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan?
- A. Ensure the traction weight hangs freely
- B. Remove the vest from the device at bedtime
- C. Cleanse sites where the pins enter the skull
- D. Screw the pins in the skull daily to tighten.
Correct Answer: C
Rationale: Neither traction nor weights are part of the halo device. The halo external fixation device includes a vest that is worn continuously and should not be removed. The neurosurgeon will discontinue it when the injury has stabilized and sufficient healing has occurred. A halo external fixation device is a static device that consists of a “halo” that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pin sites. The nurse should not tighten the pins. These are secured in the skull to maintain alignment of the cervical vertebrae. If loose, the nurse should contact the HCP for tightening.