Nokea
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
- A. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
- B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson’s disease.
- C. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training activities.
- D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
Correct Answer: A
Rationale: Feeding a client with swallowing difficulty (A) requires nursing judgment to assess aspiration risk, so it should not be delegated. Turning/positioning (B), assisting with toileting (C), and vital signs (D) are within UAP scope.
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The client being monitored while receiving tissue plasminogen activator (tPA) following an ischemic stroke opens both eyes spontaneously, mumbles inappropriate words in response to orientation questions, has no ability to move any extremities, and has decerebrate posturing in response to nailbed pressure. Based on the chart illustrated, what is the client’s Glasgow Coma Scale (GCS) score?
- A. 9 GCS score
Correct Answer: 9
Rationale: Spontaneous eye opening is scored as 4; the best verbal response of inappropriate words is scored as 3, and the best motor response of decerebrate posturing is scored as 2.
A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?
- A. It stimulated a heartbeat when bradycardia occurred during a seizure.
- B. It defibrillated a lethal rhythm that occurred during the client’s seizure.
- C. The client activates the VNS device to stop a seizure from occurring.
- D. The client activates the device at seizure onset to prevent aspiration.
Correct Answer: C
Rationale: A VNS device does not stimulate the heart to beat as a pacemaker. A VNS device does not defibrillate the heart as an implantable cardioverter/defibrillator does. A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure. The device does not have an effect on the airway or secretions.
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.
Which client should the nurse assess first after receiving the shift report?
- A. The client diagnosed with a stroke who has right-sided paralysis.
- B. The client diagnosed with meningitis who complains of photosensitivity.
- C. The client with a brain tumor who has projectile vomiting.
- D. The client with epilepsy who complains of tender gums.
Correct Answer: C
Rationale: Projectile vomiting (C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (A), photosensitivity (B), and tender gums (D) are less urgent.
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.