Nokea
The nurse is assessing the client diagnosed with meningococcal meningitis. Which assessment data would warrant notifying the HCP?
- A. Purpuric lesions on the face.
- B. Complaints of light hurting the eyes.
- C. Dull, aching, frontal headache.
- D. Not remembering the day of the week.
Correct Answer: A
Rationale: Purpuric lesions (A) indicate possible meningococcemia, a life-threatening complication requiring immediate HCP notification. Photophobia (B), headache (C), and confusion (D) are expected but less urgent.
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The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply.
- A. Sleep with the head of the bed elevated.
- B. Keep a humidifier in the room.
- C. Use caution when performing oral care.
- D. Stay on a full liquid diet until seen by the HCP.
- E. Notify the HCP if developing a cold or fever.
Correct Answer: A,C,E
Rationale: Elevating the HOB (A) reduces ICP, cautious oral care (C) prevents surgical site disruption, and reporting infections (E) is critical due to infection risk. Humidifiers (B) are not standard, and a liquid diet (D) is unnecessary unless specified.
The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse’s conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply.
- A. Blurred vision
- B. BP 198/102 mm Hg
- C. Heart rate 150 bpm
- D. Extreme headache
- E. Sweaty face and arms
Correct Answer: A,B,D,E
Rationale: Blurred vision results from the hypertension occurring with autonomic dysreflexia. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. Headache results from the hypertension occurring with autonomic dysreflexia. Sweating results from the sympathetic stimulation above the level of injury.
When the nursing team discusses the client's plan of care, which has the highest priority?
- A. Teaching the client about prevention of skin breakdown
- B. Strengthening the client's upper body muscles
- C. Confronting the client's denial of the prognosis
- D. Letting the client verbalize about the accident
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
The spouse of a recently retired man tells the nurse, 'All my husband does is sit around and watch television all day long. He is so irritable and moody. I don't want to be around him.' Which action should the nurse implement?
- A. Encourage the wife to leave the client alone.
- B. Tell the wife that he is probably developing Alzheimer's disease.
- C. Recommend that the client see an HCP for an antidepressant medication.
- D. Instruct the wife to buy him some arts and crafts supplies.
Correct Answer: C
Rationale: Irritability and mood changes post-retirement may indicate depression. Recommending an HCP evaluation for antidepressants (C) is appropriate. Leaving alone (A) ignores the issue, Alzheimer’s (B) is premature, and crafts (D) may not address mood.