Nokea
The nurse is caring for an older adult client with delirium for the third time in the past four months. While reviewing the client's medical record to determine the cause, the nurse should prioritize reviewing the client's
- A. Vital signs
- B. Height and weight
- C. Family medical history
- D. Current medications
Correct Answer: D
Rationale: Medications are a common reversible cause of recurrent delirium in the elderly.
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The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a 15-year-old who has sustained a sports-related injury
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Triage Note Triage Vital Signs
1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
The nurse assigned to the client reviews the triage note and plans care
The nurse anticipates taking which action? Prepare the client for a computed tomography (CT) scan of the head
- A. Prepare the client for a computed tomography (CT) scan of the head
- B. Perform a Glasgow Coma Scale (GCS)
- C. Encourage by mouth (PO) fluids
- D. Assess the client's pupils
- E. Prepare the client for a lumbar puncture (LP)
Correct Answer: A,A,B,A,B
Rationale: A CT scan is indicated to assess for brain injury in a client with head trauma and loss of consciousness. GCS assessment is critical to evaluate neurological status post-head injury. Encouraging PO fluids is inappropriate until a CT scan rules out increased intracranial pressure. Pupil assessment is essential to detect neurological changes post-head trauma. Lumbar puncture is not indicated unless specific conditions like meningitis are suspected.
The nurse is assessing a client with Guillain-Barré syndrome. Which of the following would be an expected finding?
- A. Hyperreflexia
- B. Perseveration
- C. Dystonia
- D. Paresthesia
Correct Answer: D
Rationale: Paresthesia (tingling/numbness) is common in Guillain-Barré syndrome due to peripheral nerve demyelination.
The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad?
- A. Hypotension, jugular venous distention, and muffled heart tones
- B. Irregular respirations, bradycardia, and widening pulse pressure
- C. Fixed pupils, hypotension, and bradycardia
- D. Bradycardia, hypotension, and bradypnea
Correct Answer: B
Rationale: Cushing's triad, indicative of increased intracranial pressure, includes irregular respirations, bradycardia, and widening pulse pressure.
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.
The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus?
- A. Rubor of the feet and ankles when the leg is in the dependent position
- B. Rapid, rhythmic muscle contractions
- C. Popping or clicking of the knee joint with movement
- D. Audible cracking and palpable grating with movement of the joints
Correct Answer: B
Rationale: Clonus is characterized by rapid, rhythmic muscle contractions, often seen in neurological disorders.