Nokea
The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client’s history of the injury should the nurse associate with the TBI? Select all that apply.
- A. The client has had no episodes of vomiting after the accident.
- B. The client remembers events before and right after the accident.
- C. The client has had headache and dizziness daily since the accident.
- D. The client has difficulty concentrating and focusing while at work.
- E. The client lost consciousness momentarily at the time of the injury.
Correct Answer: C,D,E
Rationale: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
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The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
- A. Places a suction catheter in the client’s oral cavity to stimulate the cough reflex
- B. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough
- C. Cups the hands and percusses the client’s anterior, lateral, and posterior lung fields
- D. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen
- E. Elevates the head of the bed to a high Fowler’s position if the client is sitting in bed
Correct Answer: B,E
Rationale: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse’s hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Prepare to administer an antihistamine.
- C. Test the drainage for presence of glucose.
- D. Place a 2 x 2 gauze under the nose to collect drainage.
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (C). This is the first step to guide further action. Notifying the provider (A) follows confirmation, antihistamines (B) are irrelevant, and gauze (D) is a secondary measure.
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
The nurse is teaching the client who is scheduled for an outpatient EEG. Which instruction should the nurse include?
- A. Remove all hairpins before coming in for the EEG test.
- B. Avoid eating or drinking at least 6 hours prior to the test.
- C. Some hair will be removed with a razor to place electrodes.
- D. Have blood drawn for a glucose level 2 hours before the test.
Correct Answer: A
Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results. The client should not be NPO since a usual glucose level is important for normal brain functioning. The scalp will not be shaved; the electrodes are applied with paste. There is no indication to have a serum glucose drawn before the test.
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.