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The nurse is assessing a client with a history of transient ischemic attacks (TIAs). Which finding is most concerning and should be reported immediately?
- A. Mild headache for 2 days
- B. Transient numbness in the left arm
- C. Slight dizziness when standing
- D. Occasional forgetfulness
Correct Answer: B
Rationale: Transient numbness in the left arm may indicate a TIA, which requires immediate reporting due to the risk of progression to a stroke.
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The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
- A. Help the UAP to insert the oral airway in the mouth.
- B. Tell the UAP to stop trying to insert anything in the mouth.
- C. Take no action because the UAP is handling the situation.
- D. Notify the charge nurse of the situation immediately.
Correct Answer: B
Rationale: Inserting objects during a seizure (B) risks injury to the mouth or airway and is contraindicated. The nurse must intervene immediately. Helping the UAP (A) is unsafe, taking no action (C) neglects responsibility, and notifying the charge nurse (D) delays correction.
When planning a bowel retraining program for a client with a spinal cord injury, which nursing intervention is most appropriate?
- A. Administering a stool softener twice per week
- B. Encouraging the client to consume a high-fiber diet
- C. Having the client drink two glasses of water every morning
- D. Teaching the client to self-administer daily enemas
Correct Answer: B
Rationale: A high-fiber diet promotes regular bowel movements, which is essential for bowel retraining in spinal cord injury clients.
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
- A. Decerebrate posturing observed
- B. Decorticate posturing observed
- C. Positive Kernig’s sign observed
- D. Seizure activity observed
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.
If the client had been unresponsive except to painful stimuli, which new assessment finding indicates that the client is improving?
- A. Pupils are fixed when stimulated with light.
- B. Pupils are unequal when stimulated with light.
- C. Client's Glasgow Coma Scale score is 12.
- D. Stroking the cheek with a swab causes swallowing.
Correct Answer: C
Rationale: A Glasgow Coma Scale score of 12 indicates improved responsiveness compared to being unresponsive except to painful stimuli, suggesting neurological improvement.