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The friend of an 18-year-old male client brings the client to the emergency department (ED). The client is unconscious and his breathing is slow and shallow. Which action should the nurse implement first?
- A. Ask the friend what drugs the client has been taking.
- B. Initiate an IV infusion at a keep-open rate.
- C. Call for a ventilator to be brought to the ED.
- D. Apply oxygen at 100% via nasal cannula.
Correct Answer: C
Rationale: Slow, shallow breathing in an unconscious client indicates respiratory depression, a life-threatening condition. Calling for a ventilator (C) ensures immediate airway support. Asking about drugs (A), starting an IV (B), and applying oxygen (D) follow airway management.
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Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Prepare to administer an antihistamine.
- C. Test the drainage for presence of glucose.
- D. Place a 2 x 2 gauze under the nose to collect drainage.
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (C). This is the first step to guide further action. Notifying the provider (A) follows confirmation, antihistamines (B) are irrelevant, and gauze (D) is a secondary measure.
The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
- A. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes.
- B. The client diagnosed with Parkinson’s disease who fell during the night and is complaining of difficulty walking.
- C. The client diagnosed with a cerebrovascular accident whose vital signs are P 60, R 14, and BP 198/68.
- D. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
Correct Answer: A
Rationale: Aseptic meningitis with headache and photophobia (A) is a stable condition suitable for a new graduate, requiring basic symptom management. Parkinson’s with a fall (B) needs fall risk assessment, CVA with high BP (C) requires experienced intervention, and brain tumor with visual changes (D) suggests progression needing expertise.
Which intervention is most appropriate for a client diagnosed with Bell's palsy?
- A. Reduce the amount of light in the room.
- B. Advise the client to drink liquids from a straw.
- C. Inspect the buccal pouch for food after eating.
- D. Instruct the client on how to walk with a cane.
Correct Answer: B
Rationale: Drinking from a straw helps clients with Bell's palsy manage liquids, compensating for facial muscle weakness.
Which sign or symptom in the client's medical history would most likely indicate a manifestation of the client's disease?
- A. Sudden hearing loss
- B. Sensitivity to light
- C. Drooping eyelids
- D. Protruding tongue
Correct Answer: C
Rationale: Drooping eyelids (ptosis) is a common symptom of myasthenia gravis due to muscle weakness affecting the ocular muscles.