Nokea
The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first?
- A. Set the ventilator to hyperventilate the client in preparation for suctioning.
- B. Assess the client’s lung sounds and check for peripheral cyanosis.
- C. Turn the client to the side to allow the secretions to drain from the mouth.
- D. Suction the client using the in-line suction, wait 30 seconds, and repeat.
Correct Answer: C
Rationale: Pooled secretions risk airway obstruction. Turning to the side (C) clears the airway safely without increasing ICP. Hyperventilation (A) and suctioning (D) may raise ICP, and assessment (B) delays intervention.
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Based on the nurse's knowledge, which characteristic is found in Alzheimer's disease that distinguishes it from other dementias?
- A. Destruction of brain cells from hypoxia
- B. Destruction of brain cells from a stroke
- C. Neurofibrillary tangles and plaques in the brain
- D. A superficial infection in the meninges of the brain
Correct Answer: C
Rationale: Neurofibrillary tangles and amyloid plaques are hallmark pathological features of Alzheimer's disease.
The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?
- A. Do you have trouble hearing?'
- B. Are you allergic to any type of dairy products?'
- C. Have you eaten anything in the last eight (8) hours?'
- D. Are you uncomfortable in closed spaces?'
Correct Answer: D
Rationale: MRI scans require lying still in a confined space, so assessing for claustrophobia (D) is critical to ensure patient safety and comfort. Hearing issues (A), dairy allergies (B), and recent eating (C) are not relevant to MRI preparation.
Because carbamazepine (Tegretol) can cause liver dysfunction, the client's discharge plan should include instructions to report which symptom?
- A. Unusual bleeding
- B. Yellowing of the skin
- C. Cloudy urine
- D. Mottled skin
Correct Answer: B
Rationale: Yellowing of the skin (jaundice) indicates potential liver dysfunction, a known side effect of carbamazepine.
The nurse is caring for the client who has limited intake due to dysphagia following an ischemic stroke. Which serum laboratory result should the nurse review to verify that the client is dehydrated?
- A. Elevated serum creatinine
- B. Elevated blood urea nitrogen
- C. Decreased hemoglobin
- D. Decreased prealbumin
Correct Answer: B
Rationale: The serum creatinine is elevated with renal insufficiency or renal failure. The BUN is elevated when the client is dehydrated due to the lack of fluid volume to excrete waste products. The Hgb is decreased with blood loss or anemia from nutritional deficiencies, not with dehydration. A decreased prealbumin indicates a nutritional deficiency.
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.