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The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.
- A. Monitor the pulse oximetry reading.
- B. Provide pureed foods six (6) times a day.
- C. Encourage coughing and deep breathing.
- D. Assess for autonomic dysreflexia.
- E. Administer intravenous corticosteroids.
Correct Answer: A,C,D
Rationale: Cervical SCI risks respiratory compromise and autonomic dysreflexia. Monitoring pulse oximetry (A) ensures oxygenation, coughing/deep breathing (C) prevents pneumonia, and assessing for autonomic dysreflexia (D) detects dangerous BP spikes. Pureed foods (B) are unnecessary without dysphagia, and corticosteroids (E) are not standard for acute SCI management.
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The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
- A. Assess the client’s neurological status every hour.
- B. Monitor the client’s heart rhythm via telemetry.
- C. Administer an anticonvulsant medication by intravenous push.
- D. Prepare to administer a glucocorticosteroid orally.
Correct Answer: C
Rationale: Status epilepticus is a life-threatening continuous seizure requiring immediate IV anticonvulsants (C), such as lorazepam or phenytoin, to stop the seizure. Neurological assessment (A) and telemetry (B) are supportive, and glucocorticoids (D) are not indicated.
What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.
The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client’s treatment with mannitol?
- A. Serum osmolarity
- B. White blood cell count
- C. Serum cholesterol
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Mannitol (Osmitrol), an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage. The WBC count is not affected by mannitol. Serum cholesterol is not affected by mannitol. ESR is not affected by mannitol.
The client diagnosed with Parkinson’s disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions?
- A. All of my spouse’s emotions will slow down now just like his body movements.'
- B. My spouse may experience hallucinations until the medication starts working.'
- C. I will schedule appointments late in the morning after his morning bath.'
- D. It is fine if we don’t follow a strict medication schedule on weekends.'
Correct Answer: C
Rationale: Scheduling appointments late in the morning (C) accommodates Parkinson’s patients’ morning stiffness and medication timing, indicating understanding. Emotional slowing (A) is incorrect, hallucinations (B) are a side effect not limited to initiation, and strict medication schedules (D) are critical.
What should the nurse warn a client with multiple sclerosis to avoid?
- A. Hot weather
- B. Wet climates
- C. Your diet
- D. Cold temperatures
Correct Answer: A
Rationale: Hot weather can exacerbate MS symptoms by increasing body temperature, which impairs nerve conduction.