Nokea
The nurse in the ED documents that the newly admitted client is 'postictal upon transfer.' What did the nurse observe?
- A. Yellowing of the skin due to a liver condition
- B. Drowsy or confused state following a seizure
- C. Severe itching of the eyes from an allergic reaction
- D. Abnormal sensations including tingling of the skin
Correct Answer: B
Rationale: Jaundice and icterus are terms for yellowing of the skin. The client had experienced a tonic-clonic seizure recently and is now in a state of deep relaxation and is breathing quietly. During this period the client may be unconscious or awaken gradually, but is often confused and disoriented. Often the client is amnesic regarding the seizure. Pruritus is a term for itching. Paresthesia is the term for abnormal sensations such as tingling and burning of the skin.
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Which behavior is a risk factor for developing and spreading bacterial meningitis?
- A. An upper respiratory infection (URI).
- B. Unprotected sexual intercourse.
- C. Chronic alcohol consumption.
- D. Use of tobacco products.
Correct Answer: A
Rationale: URI (A) increases the risk of bacterial meningitis by facilitating bacterial invasion. Sexual intercourse (B), alcohol (C), and tobacco (D) are not direct risk factors.
Which statement by a client with Alzheimer's disease indicates a need for further safety teaching?
- A. I'll use a nightlight in my bedroom.'
- B. I can cook meals on the stove alone.'
- C. I'll keep my medications in a locked box.'
- D. I'll wear a medical alert bracelet.'
Correct Answer: B
Rationale: Cooking alone on the stove poses a fire risk for clients with Alzheimer's due to memory and judgment impairments.
When is the best time to clip the client's hair?
- A. The night before surgery
- B. In the morning, after a shower
- C. Right before entering the operating room
- D. Before surgery, in the operating room area
Correct Answer: D
Rationale: Clipping hair in the operating room area minimizes infection risk by reducing the time the scalp is exposed.
The nurse is caring for the older adult client with normal pressure hydrocephalus (NPH). Which treatment measure should the nurse anticipate?
- A. Carotid endarterectomy
- B. Ventriculoperitoneal shunt
- C. Insertion of a lumbar drain
- D. Anticonvulsant medications
Correct Answer: B
Rationale: A carotid endarterectomy involves removal of plaque from the carotid artery. NPH is treated with the placement of a permanent shunt in a lateral ventricle of the brain to the peritoneal cavity. The excess CSF drains into the peritoneal cavity. A lumbar drain can be used to remove CSF with disorders that increase CSF in the subarachnoid space in the lumbar area; this does not remain permanently. Anticonvulsant medications are used to treat seizures.
The nurse should place the client in which position?
- A. Knee-chest (genupectoral) position
- B. Sitting in an orthopneic position
- C. Side-lying position with his neck flexed
- D. Prone position with the head turned to the left side
Correct Answer: C
Rationale: The side-lying position with the neck flexed facilitates access to the lumbar spine for a lumbar puncture and helps open the intervertebral spaces.