Nokea
The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first?
- A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a '2' on a 1-to-10 scale.
- B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- C. The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
Correct Answer: B
Rationale: Inability to move toes in a T10 SCI (B) may indicate neurological deterioration or edema, requiring immediate assessment. Mild headache (A), emotional distress (C), and resolving hemiparesis (D) are less urgent.
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When documenting a seizure, which information is most important to include initially?
- A. The time the seizure started
- B. The duration of the seizure
- C. The client's mood just before the seizure
- D. The client's comments after the seizure
Correct Answer: A
Rationale: Documenting the time the seizure started is critical for tracking seizure patterns and guiding treatment.
Of the following nursing observations, which is most important to discuss the client's condition?
- A. The client has a chronic cough.
- B. The client is becoming jittery.
- C. The client's skin is warm and clammy.
- D. The client develops diarrhea.
Correct Answer: A
Rationale: A chronic cough increases intrathoracic pressure, which can elevate intracranial pressure and risk aneurysm rupture.
The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
The client diagnosed with ALS asks the nurse, 'I know this disease is going to kill me. What will happen to me in the end?' Which statement by the nurse would be most appropriate?
- A. You are afraid of how you will die?'
- B. Most people with ALS die of respiratory failure.'
- C. Don’t talk like that. You have to stay positive.'
- D. ALS is not a killer. You can live a long life.'
Correct Answer: B
Rationale: Providing factual information about respiratory failure (B) addresses the client’s question honestly while respecting their need for clarity. Reflecting fear (A) is vague, dismissing concerns (C) is untherapeutic, and denying prognosis (D) is inaccurate.
Which client behavior during a seizure requires immediate intervention?
- A. Lip smacking
- B. Rhythmic limb jerking
- C. Incontinence
- D. Tongue biting
Correct Answer: D
Rationale: Tongue biting during a seizure can cause airway obstruction or severe injury, requiring immediate intervention to protect the airway.