Nokea
The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room?
- A. Determine if the client has loss of vision in the same half of each visual field.
- B. Find out if the client prefers the bed by the window or by the bathroom.
- C. Request dietary to place the meat at 12:00 on each plate and vegetables at 09:00 and 15:00.
- D. Request a physical therapy consult to assess the client's mobility issues.
Correct Answer: A
Rationale: Homonymous hemianopia (loss of half the visual field) from a CVA affects safety and orientation, requiring immediate assessment. Bed preference, dietary setup, and PT consults are secondary.
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The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
- A. Ensure that all room walls are painted with colors that blend.
- B. Use a white board and a black marker when writing out lists.
- C. Place Velcro tabs on wall light switches to ease locating them.
- D. Ensure that doorknobs on the doors are a bright contrasting color.
- E. Match the color of dishes with the color of table-cloths or placemats.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.
The elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
- A. Elderly clients react to pain the same way any other age group does.
- B. The elderly client usually requires more pain medication.
- C. Reaction to painful stimuli may be decreased with age.
- D. The elderly client should use the Wong scale to assess pain.
Correct Answer: C
Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.
The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first?
- A. Flush the eye thoroughly with saline solution and apply a pressure bandage.
- B. Apply an eye shield to the affected eye and give a prescribed oral analgesic.
- C. Notify the HCP; prepare for transport to a facility for ophthalmological care.
- D. Patch both eyes and place the client in a prone position until blurring stops.
Correct Answer: C
Rationale: The nurse should contact the HCP and secure an ophthalmological evaluation promptly. Flushing the eye and applying a pressure bandage may cause further injury and delay treatment. Applying an eye shield and analgesic or patching both eyes delays securing treatment.
The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test?
- A. A positive result will be evident within one minute of injection of Tensilon if she has myasthenia gravis.
- B. This is of diagnostic value in only 25% of patients with myasthenia gravis.
- C. Administration of Tensilon causes an immediate decrease in muscle strength for about an hour in persons with myasthenia gravis.
- D. Tensilon works by blocking the action of acetylcholine at the myoneural junction.
Correct Answer: A
Rationale: A positive Tensilon test shows increased muscle strength within one minute, confirming myasthenia gravis, as Tensilon enhances acetylcholine activity.
An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
- A. Increased cerebral blood flow
- B. Respiratory depression
- C. Increased intracranial pressure
- D. Hyperoxygenation of the cerebrum
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.