Nokea
The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
- A. The client and their family members will arrange for rehabilitation.
- B. The rehabilitation plan should be implemented early in the client's treatment.
- C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities.
- D. Long-term care should be arranged, as the client can no longer perform self-care.
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.
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The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 1 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Which of the following assessment findings require immediate follow-up?
- A. Neurological assessment findings
- B. Pulse and temperature
- C. Gastrointestinal assessment findings
- D. Influenza vaccination status
- E. Daily smoking habit
- F. Blood pressure and pulse oximetry reading
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.
The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?
- A. Prepares to administer intravenous valproate.
- B. Place the client in a lateral position.
- C. Activates the rapid response team (RRT).
- D. Loosens any restrictive clothing.
Correct Answer: A
Rationale: Valproate is not a first-line treatment for status epilepticus; benzodiazepines like lorazepam are preferred.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 5 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each physician order, click to specify the appropriate nursing intervention: Lumbar puncture
- A. Assess the client for an allergy to contrast dye
- B. Obtain laboratory work prior to the procedure
- C. Position the client flat before the procedure
- D. Monitor the client's temperature for efficacy
- E. Place an incontinence pad under the client for increased urinary output
- F. administer immediately after lumbar puncture
- G. establish a patent vascular access device
Correct Answer: B,F,G
Rationale: Obtaining labs (e.g., coagulation studies) ensures safety before lumbar puncture. Ketorolac may help reduce fever; monitoring temperature assesses its efficacy. Ceftriaxone is administered post-lumbar puncture to treat confirmed or suspected bacterial meningitis. Padding the bed prevents injury during potential seizures.
The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider?
- A. Trazodone
- B. Modafinil
- C. Diazepam
- D. Fluoxetine
Correct Answer: B
Rationale: Modafinil is a wakefulness-promoting agent used to treat excessive daytime sleepiness in narcolepsy. Trazodone, diazepam, and fluoxetine are not indicated for narcolepsy.
The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
- A. The client can control the motorized wheelchair.
- B. The client states she wants to stand up with assistance.
- C. The client says she wants to move her toes.
- D. The client says she regained her bladder control.
Correct Answer: A
Rationale: Controlling a motorized wheelchair indicates improved upper body function, appropriate for C6-C7 injury.