Nokea
The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?
- A. Active range of motion in both arms
- B. Scant drainage on the dressing
- C. Difficulty swallowing liquids
- D. Soreness at the operative site
Correct Answer: C
Rationale: Difficulty swallowing (dysphagia) post-cervical spinal surgery could indicate complications like nerve damage or swelling, requiring immediate follow-up.
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The nurse is assessing a client taking prescribed lamotrigine. Which client finding requires immediate follow-up?
- A. Abnormal dreams
- B. Skin blistering
- C. Dyspepsia
- D. Xerostomia
Correct Answer: B
Rationale: Skin blistering is a serious adverse effect of lamotrigine, potentially indicating Stevens-Johnson syndrome or toxic epidermal necrolysis, both life-threatening conditions requiring immediate medical attention. Abnormal dreams, dyspepsia, and xerostomia are less severe side effects that do not typically require urgent follow-up.
The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding?
- A. Diplopia
- B. Butterfly rash
- C. Facial muscle weakness
- D. Shuffling gait
- E. Ptosis
Correct Answer: A,C,E
Rationale: Diplopia, facial muscle weakness, and ptosis are common in myasthenia gravis due to neuromuscular junction dysfunction.
The nurse is caring for a client with a spinal cord injury. Which actions should the nurse take if the client develops autonomic dysreflexia?
- A. Notify the rapid response team.
- B. Assess the client's bladder for distention.
- C. Place the client in a modified Trendelenburg position.
- D. Prepare the client for an emergency lumbar puncture (LP).
- E. Obtain and monitor the client's blood pressure.
- F. Obtain a prescription for a vasopressor.
Correct Answer: A,B,E
Rationale: Notifying RRT, assessing bladder distention, and monitoring blood pressure address autonomic dysreflexia.
A client is in the intensive care unit, admitted with a subdural hematoma. Just before shift change, as the nurse prepares to provide a bedside clinical hand-off and report, an alarm goes off, indicating a drop in the client's blood pressure. The initial action of the nurse would be:
- A. Turn the alarm off and inform the oncoming nurse of the drop in the client's blood pressure.
- B. Lower the blood pressure alarm limits on the monitor to allow for an uninterrupted bedside clinical hand-off and report.
- C. Perform the bedside clinical hand-off and report, including information regarding the client's blood pressure drop.
- D. Assess the client and intervene as needed.
Correct Answer: D
Rationale: Assessing and intervening for a blood pressure drop is the priority to ensure patient safety.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Presbycusis
- B. Ototoxic substance
- C. Foreign body
- D. Exposure to loud noise
- E. Edema
Correct Answer: A,B,D
Rationale: Presbycusis, ototoxic substances, and loud noise exposure cause sensorineural hearing loss by damaging the inner ear or auditory nerve.