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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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The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies.
- A. The client has a recurrent temperature of 100.6°F.
- B. The client has a decreased complaint of headache.
- C. The client comments that the meal has no taste.
Correct Answer: B
Rationale: A fever of 100.6°F (B) in encephalitis may indicate worsening infection or inflammation, requiring immediate intervention. Decreased headache (C) suggests improvement, and taste loss (D) is less urgent. Facial palsies are noted but not an option.
Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis?
- A. This regimen helps to decrease the purulent exudate surrounding the meninges.
- B. These medications will decrease intracranial pressure and brain metabolism.
- C. These medications will increase the client’s memory and orientation.
- D. This will help prevent a yeast infection secondary to antibiotic therapy.
Correct Answer: B
Rationale: Alternating antipyretics and NSAIDs (B) reduces fever and inflammation, lowering ICP and brain metabolism in meningitis. Exudate (A) is addressed by antibiotics, memory/orientation (C) is not directly affected, and yeast infections (D) are unrelated.
Based on the nurse's knowledge, which characteristic is found in Alzheimer's disease that distinguishes it from other dementias?
- A. Destruction of brain cells from hypoxia
- B. Destruction of brain cells from a stroke
- C. Neurofibrillary tangles and plaques in the brain
- D. A superficial infection in the meninges of the brain
Correct Answer: C
Rationale: Neurofibrillary tangles and amyloid plaques are hallmark pathological features of Alzheimer's disease.
When preparing the client for the upcoming positron emission tomography (PET) scan, the nurse instructs the client to avoid which substances the day before the test? Select all that apply.
- A. Caffeine
- B. Shampoo
- C. Diuretics
- D. Shellfish
- E. Alcohol
- F. Tobacco
Correct Answer: A,E,F
Rationale: Caffeine, alcohol, and tobacco can affect cerebral metabolism and blood flow, potentially altering PET scan results.