Nokea
The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing DI?
- A. Blood glucose level at 230 mg/dL
- B. Urinary output 1500 mL over 4 hours
- C. Urine specific gravity at 1.042
- D. Somnolent when previously alert
Correct Answer: B
Rationale: Elevated glucose levels are not associated with DI. The lack of ADH that occurs in DI results in excreting a large amount of pale, dilute urine. The urine of clients with DI is very dilute and therefore has a very low, not high, specific gravity. Decrease in level of consciousness is not directly associated with DI but rather with craniocerebral swelling or bleeding from the trauma.
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The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest 'Lou Gehrig’s' disease. Which is the nurse’s most appropriate response?
- A. “Muscle weakness can occur from working too much. Avoid thinking the worst.”
- B. “Tell me what has you thinking that you might have Lou Gehrig’s disease.”
- C. “Have you been having trouble remembering things along with this weakness?”
- D. “That is a good question. We will be doing tests to figure out what is going on.”
Correct Answer: B
Rationale: There is no information that the client is working too much. Telling the client to avoid thinking the worst belittles the client’s concern. This is the most appropriate response because it focuses on the client’s concern, encourages verbalization, and solicits more information. ALS (Lou Gehrig’s disease) is a degenerative disease that affects the motor system and does not have a dementia component; thus, a question about memory is inappropriate. This response does not take the client seriously and does not address the client’s concern.
The student nurse asks the nurse, 'Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?' The nurse would base the response on which scientific rationale?
- A. This is part of the routine neurological examination.
- B. This is done to determine if the client has diplopia.
- C. This assesses the amount of brain damage.
- D. This is done to indicate if there is a rebound effect on the brain.
Correct Answer: B
Rationale: Frontal head injuries may affect the occipital lobe or optic pathways, causing diplopia (double vision, B). Routine exams (A) are broader, brain damage (C) is not specific, and rebound effect (D) is not a term used here.
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
When planning care for this client, which equipment is most important for the nurse to keep at the bedside?
- A. A cardiac defibrillator in case of cardiac arrest
- B. A suction machine in case of compromised swallowing
- C. A cooling blanket in case of hyperthermia
- D. An IV infusion pump for fluid administration
Correct Answer: B
Rationale: A suction machine is essential to clear secretions in myasthenia gravis clients with compromised swallowing, preventing aspiration.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.