Nokea
The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report?
- A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
- B. The client with an L4 SCI who is crying and very upset about being discharged home.
- C. The client with an L2 SCI who is complaining of a headache and feeling very hot.
- D. The client with a T4 SCI who is unable to move the lower extremities.
Correct Answer: A
Rationale: Dyspnea and crackles in a C6 SCI patient (A) suggest respiratory compromise, a life-threatening condition requiring immediate assessment. Emotional distress (B), headache (C), or expected paralysis (D) are less urgent.
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Before discharge, the nurse instructs the client about administering subcutaneous injections and correctly explains the client should rotate injections between which two areas?
- A. Thighs and hips
- B. Forearms and hips
- C. Thighs and abdomen
- D. Abdomen and buttocks
Correct Answer: C
Rationale: Rotating injections between the thighs and abdomen minimizes tissue damage and ensures consistent absorption.
The son of a client diagnosed with ALS asks the nurse, 'Is there any chance that I could get this disease?' Which statement by the nurse would be most appropriate?
- A. It must be scary to think you might get this disease.'
- B. No, this disease is not genetic or contagious.'
- C. ALS does have a genetic factor and runs in families.'
- D. If you are exposed to the same virus, you may get the disease.'
Correct Answer: C
Rationale: About 5–10% of ALS cases are familial, with a genetic component (C). Reflecting fear (A) is vague, denying genetics (B) is incorrect, and viral causes (D) are not established.
Which behavior is a risk factor for developing and spreading bacterial meningitis?
- A. An upper respiratory infection (URI).
- B. Unprotected sexual intercourse.
- C. Chronic alcohol consumption.
- D. Use of tobacco products.
Correct Answer: A
Rationale: URI (A) increases the risk of bacterial meningitis by facilitating bacterial invasion. Sexual intercourse (B), alcohol (C), and tobacco (D) are not direct risk factors.
Which finding in a client post-stroke indicates a need for immediate intervention?
- A. Blood pressure of 180/100 mmHg
- B. Mild weakness in the right arm
- C. Difficulty finding words
- D. Fatigue after physical therapy
Correct Answer: A
Rationale: Severe hypertension post-stroke increases the risk of hemorrhage or further brain injury, requiring immediate intervention.
The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.