Nokea
The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful?
- A. Adoption is an option to complete your family but not put your life in jeopardy.
- B. Conception is not impaired, the birth process is determined with the health care provider.
- C. Birth via surrogate is best because your baby can be implanted in another woman.
- D. Sterilization is best; it would be difficult to care for a baby in your condition.
Correct Answer: B
Rationale: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.
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A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?
- A. The client is a heart transplant recipient.
- B. The client's medications include warfarin (Coumadin).
- C. The client is HIV positive.
- D. The client has a history of concussions from playing hockey.
Correct Answer: B
Rationale: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern.
The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae. From which location will bone be taken for the fusion?
- A. Iliac crest
- B. Floating rib
- C. Femur
- D. Mandible
Correct Answer: A
Rationale: To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
- A. Extreme thirst
- B. Intake and output
- C. Nutritional status
- D. Body temperature
Correct Answer: D
Rationale: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?
- A. Extradural hematoma
- B. Epidural hematoma
- C. Subdural hematoma
- D. Intracranial hematoma
Correct Answer: B
Rationale: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
- A. Acetaminophen may be administered for aches.
- B. Observe for any signs of behavioral changes.
- C. A light meal may be eaten if desired.
- D. Follow up with regular physician is encouraged.
Correct Answer: B
Rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.