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 diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?
- A. The client has purposeful movement with painful stimuli.
- B. The client has assumed adduction of the upper extremities.
- C. The client is aimlessly thrashing in the bed.
- D. The client has become flaccid and does not respond to stimuli.
Correct Answer: D
Rationale: Flaccid paralysis and unresponsiveness (D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (A) or thrashing (C) suggest improvement, and adduction (B) is not a standard indicator.
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.
Which intervention should be added to the client's care plan in relation to this latest finding?
- A. Have the client wear dark glasses when in bright light.
- B. Cover the client's affected eye with an eye patch.
- C. Approach the client from the unaffected side.
- D. Position food on the tray resembling the face of a clock.
Correct Answer: C
Rationale: Approaching from the unaffected side ensures the client with hemianopia can see the nurse, compensating for visual field loss.
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
- A. Obtain an informed consent from the client or significant other.
- B. Have the client empty the bladder prior to the procedure.
- C. Place the client in a side-lying position with the back arched.
- D. Instruct the client to breathe rapidly and deeply during the procedure.
- E. Explain to the client what to expect during the procedure.
Correct Answer: A,B,C,E
Rationale: Informed consent (A) is required, emptying the bladder (B) ensures comfort, side-lying with back arched (C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (D) is not advised.
The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.