Nokea
The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain?
- A. Respiratory rate
- B. Blood Pressure
- C. Pulse
- D. Temperature
Correct Answer: A
Rationale: Cervical spinal cord injury can impair respiratory function, making respiratory rate the priority.
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The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
- A. Place an eye patch over the affected eye
- B. Instruct the client to turn their head from side to side
- C. Speak slowly, clearly, and in a deeper voice
- D. Provide the client with ear plugs to promote rest
Correct Answer: B
Rationale: Head turning compensates for the visual field loss in homonymous hemianopia.
The RN is caring for a client who is recovering from carotid endarterectomy. Which assessment would the nurse recognize as a sign that the client experienced hypoglossal nerve injury?
- A. Tongue deviation
- B. Inspiratory stridor
- C. Tracheal deviation
- D. Severe headache
Correct Answer: A
Rationale: Hypoglossal nerve injury (cranial nerve XII) causes tongue deviation due to impaired tongue movement.
The nurse is reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for phenytoin toxicity
- D. Document the result as within normal limits
Correct Answer: D
Rationale: A phenytoin level of 12 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the nurse should document the result as normal. Non-adherence, skipping doses, or toxicity assessment are not indicated.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
- A. Peripheral artery disease
- B. Accelerated hypertension
- C. Migraine headache
- D. Angina
Correct Answer: C
Rationale: Sumatriptan is a triptan specifically used to treat migraine headaches by constricting blood vessels and reducing inflammation. It is not used for peripheral artery disease, hypertension, or angina.
The nurse is performing an assessment on a client with Wernicke's aphasia. Which client finding would be consistent with this diagnosis?
- A. Loss of ability to execute or carry out skilled movements.
- B. Cannot express any words.
- C. Cannot swallow liquids.
- D. Speaks with normal fluency and prosody.
Correct Answer: D
Rationale: Wernicke's aphasia is characterized by fluent but nonsensical speech with preserved fluency and prosody.