Nokea
The nurse is caring for the client who has limited intake due to dysphagia following an ischemic stroke. Which serum laboratory result should the nurse review to verify that the client is dehydrated?
- A. Elevated serum creatinine
- B. Elevated blood urea nitrogen
- C. Decreased hemoglobin
- D. Decreased prealbumin
Correct Answer: B
Rationale: The serum creatinine is elevated with renal insufficiency or renal failure. The BUN is elevated when the client is dehydrated due to the lack of fluid volume to excrete waste products. The Hgb is decreased with blood loss or anemia from nutritional deficiencies, not with dehydration. A decreased prealbumin indicates a nutritional deficiency.
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The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
- A. The assistant places a gait belt around the client's waist prior to ambulating.
- B. The assistant places the client on the back with the client's head to the side.
- C. The assistant places a hand under the client's right axilla to move up in bed.
- D. The assistant praises the client for attempting to perform ADLs independently.
Correct Answer: C
Rationale: Placing a hand under the axilla (C) to move a client with right-sided paralysis risks shoulder subluxation or injury to the weak side. A gait belt (A) is appropriate for safe ambulation, positioning with head to the side (B) prevents aspiration, and praising independence (D) is therapeutic.
The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.
Which postoperative complication should the nurse monitor most closely after a craniotomy?
- A. Hypotension
- B. Cerebrospinal fluid leak
- C. Mild fever
- D. Constipation
Correct Answer: B
Rationale: A cerebrospinal fluid leak is a critical complication post-craniotomy, increasing infection risk and requiring immediate intervention.
When the nurse describes the myelogram procedure to the client, which statement is most accurate?
- A. Part of the test involves a lumbar puncture.'
- B. You will be asked to change positions frequently.'
- C. Dye is instilled into a vein in your arm.'
- D. Light anesthesia is administered during the test.'
Correct Answer: A
Rationale: A myelogram involves a lumbar puncture to inject contrast dye into the spinal canal for imaging.