Nokea
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
- A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours.
- B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
- C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.
- D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
Correct Answer: C
Rationale: A GCS score of 6 (C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (A) is standard for concussion, left-sided weakness (B) is concerning but less acute, and expressive aphasia (D) is stable.
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Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
When assisting the client with activities of daily living (ADLs), which approach is best?
- A. Limit the time for performing ADLs to 30 minutes.
- B. Eliminate whatever tasks the client cannot perform.
- C. Let the client rest between activities.
- D. Perform all of the client's ADLs at this time.
Correct Answer: C
Rationale: Allowing rest between activities conserves energy and supports the client's independence during an MS exacerbation.
The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
- A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78.
- B. The client complains of generalized body aches and pains.
- C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA).
- D. The client becomes lethargic and is difficult to arouse using verbal stimuli.
Correct Answer: D
Rationale: Lethargy and difficulty arousing (D) indicate neurological deterioration, requiring immediate intervention. Mild fever (A), body aches (B), and positive ELISA (C) are expected.
The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson’s Disease. Which priority intervention should the nurse implement?
- A. Keep the bed low and call light in reach.
- B. Provide a regular diet of three (3) meals per day.
- C. Obtain an order for home health to see the client.
- D. Perform the Braden scale skin assessment.
Correct Answer: A
Rationale: Parkinson’s increases fall risk due to bradykinesia and rigidity. Keeping the bed low and call light in reach (A) prioritizes safety. Diet (B), home health (C), and skin assessment (D) are secondary.
When the client asks why fluids are being restricted, which explanation by the nurse is best?
- A. Large amounts of fluid may contribute to vomiting.'
- B. The kidneys need to conserve fluid output.'
- C. Fluid restriction reduces the volume in the cranium.'
- D. The prescribed volume is sufficient for relieving thirst.'
Correct Answer: C
Rationale: Fluid restriction reduces intracranial volume, minimizing the risk of increased intracranial pressure post-craniotomy.