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The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document?
- A. Hemiparesis of the client's left arm and apraxia.
- B. Paralysis of the right side of the body and ataxia.
- C. Homonymous hemianopsia and diplopia.
- D. Impulsive behavior and hostility toward family.
Correct Answer: B
Rationale: A left-sided CVA affects the right side of the body due to the brain's contralateral control. Paralysis or hemiparesis of the right side is a common manifestation, and ataxia (impaired coordination) may also occur. Hemiparesis of the left arm would indicate a right-sided CVA, visual deficits like homonymous hemianopsia are possible but less specific to motor loss, and behavioral changes are not directly related to motor deficits.
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The nurse’s client with a T2 SCI is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse’s interventions in the order that these should be performed.
- A. Elevate the HOB to 90 degrees.
- B. Lower the end of the bed so feet are dependent.
- C. Remove elastic stocking and other constricting devices; assess below the level of injury.
- D. Retake the blood pressure after being upright for 2 to 3 minutes.
- E. Administer a pm prescribed sublingual nifedipine for continued elevated BP.
- F. Perform digital removal of impacted stool (last BM found to be 10 days ago).
- G. Inform the HCP of the incident, measures taken, and client response.
Correct Answer: C,A,B,G,F,E,D
Rationale: Elevate the HOB to 90 degrees. This initial quick action may help lower the client’s BP. Lower the end of the bed so feet are dependent. Placing the feet lower than the head will help decrease blood return and may help lower the BP. Remove elastic stocking and other constricting devices; assess below the level of injury. Anything constricting below the level of injury can be the stimulus that precipitates autonomic dysreflexia. The nurse can assess for other precipitating factors, such as a full bladder, while removing constricting devices. Retake the BP after being upright for 2 to 3 minutes. Elevating the HOB, lowering the feet, and removing constricting devices may have lowered the BP. If not, further interventions are needed. Administer a pm prescribed sublingual nifedipine for continued elevated BP. If the BP remains elevated, the prescribed antihypertensive medication, such as nifedipine (Procardia), should be given next to quickly lower the BP. Perform digital removal of impacted stool (last BM found to be 10 days ago). Digitally removing stool impaction may cause a further spike in BP, so that should be completed after the BP medication is administered. Inform the HCP of the incident, measures taken, and client response. This is last because a pro antihypertensive medication had already been prescribed. Care of the client is priority.
Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease)?
- A. Discuss a percutaneous gastrostomy tube.
- B. Explain how a fistula is accessed.
- C. Provide an advance directive.
- D. Refer to a physical therapist for leg braces.
Correct Answer: C
Rationale: ALS is progressive and terminal. Providing an advance directive (C) ensures the client’s wishes are respected early. Gastrostomy (A) is later, fistulas (B) are unrelated, and leg braces (D) are less urgent.
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
- A. Examine pupil reactions to light.
- B. Assess level of consciousness.
- C. Observe for seizure activity.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.
The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.
When a client is injured during a seizure, which fact is most important to document on the incident (accident) report to reduce the risk of liability?
- A. The client was assigned to a licensed nurse.
- B. The signal cord was within the client's reach.
- C. The client's vital signs had been stable.
- D. The client was last observed reading.
Correct Answer: B
Rationale: Documenting that the signal cord was within reach indicates that safety measures were in place, reducing liability.