Nokea
The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which findings as expected neurological changes for the client with a concussion? Select all that apply.
- A. Amnesia
- B. Asymmetrical pupillary constriction
- C. Brief loss of consciousness
- D. Headache
- E. Loss of vision
Correct Answer: A,C,D
Rationale: Amnesia (A), brief loss of consciousness (C), and headache (D) are common symptoms of concussion due to temporary brain dysfunction.
You may also like to solve these questions
The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge?
- A. Client on chemotherapy who started antibiotics today for cellulitis of the leg
- B. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours
- C. Client with diabetes who has nausea, abdominal pain, and vomiting
- D. Client with ulcerative colitis and diarrhea who has developed fever and vomiting
Correct Answer: B
Rationale: The client with resolved asthma exacerbation, not requiring oxygen or nebulizers for 12 hours, is stable and safe for discharge, unlike the others with active complications.
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, 'I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!' Which of the following is the most appropriate response by the nurse?
- A. I can tell that you want me to go, so I will call in a few days to see how you are doing.
- B. I know you are frustrated with losing control of your life.
- C. It sounds like you are angry. Tell me what's bothering you.
- D. Okay. I'll just check your blood pressure and then go.
Correct Answer: C
Rationale: Acknowledging the client's anger and inviting them to express their feelings promotes therapeutic communication, helping to de-escalate the situation and address underlying concerns.
The nurse reinforces teaching to a client prescribed isoniazid, rifampin, ethambutol, and pyrazinamide to treat active tuberculosis. Which of the following instructions associated with the adverse effects of rifampin is most important for the nurse to include?
- A. Notify the health care provider if your urine is red
- B. Take acetaminophen every 6 hours for drug-associated joint pain while taking this medication
- C. Wear eyeglasses instead of soft contact lenses while taking this medication
- D. You can stop taking the medications as soon as one sputum culture comes back normal
Correct Answer: C
Rationale: Rifampin can stain soft contact lenses orange-red, so wearing eyeglasses prevents this issue, making it a key instruction for adherence.
The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports
- A. straining to have a bowel movement
- B. going an entire workday without needing to urinate
- C. using over-the-counter artificial saliva products for dry mouth
- D. experiencing occasional dizziness in the morning and with position changes
Correct Answer: B
Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.