Nokea
The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care?
- A. Administer antibiotics.
- B. Obtain a sputum culture.
- C. Monitor the pulse oximeter.
- D. Assess intake and output.
Correct Answer: A
Rationale: Bacterial meningitis requires prompt antibiotic administration (A) as a collaborative intervention with the provider. Sputum culture (B) is not relevant, pulse oximetry (C) is supportive, and intake/output (D) is a nursing action.
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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 client is withdrawing from a heroin addiction. Which interventions should the nurse implement? Select all that apply.
- A. Initiate seizure precautions.
- B. Check vital signs every eight (8) hours.
- C. Place the client in a quiet, calm atmosphere.
- D. Have a consent form signed for HIV testing.
- E. Provide the client with sterile needles.
Correct Answer: C
Rationale: Heroin withdrawal causes discomfort but not seizures, so seizure precautions (A) are unnecessary. Vital signs every 8 hours (B) is too infrequent; every 4 hours is standard. A quiet, calm atmosphere (C) reduces stimulation. HIV testing (D) requires consent but isn’t withdrawal-specific, and sterile needles (E) are inappropriate.
Which client behavior during a seizure requires immediate intervention?
- A. Lip smacking
- B. Rhythmic limb jerking
- C. Incontinence
- D. Tongue biting
Correct Answer: D
Rationale: Tongue biting during a seizure can cause airway obstruction or severe injury, requiring immediate intervention to protect the airway.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.
A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?
- A. It stimulated a heartbeat when bradycardia occurred during a seizure.
- B. It defibrillated a lethal rhythm that occurred during the client’s seizure.
- C. The client activates the VNS device to stop a seizure from occurring.
- D. The client activates the device at seizure onset to prevent aspiration.
Correct Answer: C
Rationale: A VNS device does not stimulate the heart to beat as a pacemaker. A VNS device does not defibrillate the heart as an implantable cardioverter/defibrillator does. A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure. The device does not have an effect on the airway or secretions.