Nokea
The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
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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.
The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
Which intervention is most effective for managing autonomic dysreflexia in a client with a spinal cord injury?
- A. Elevate the head of the bed.
- B. Administer a bronchodilator.
- C. Apply a warm compress to the abdomen.
- D. Insert a urinary catheter immediately.
Correct Answer: D
Rationale: Autonomic dysreflexia is often triggered by bladder distension; immediate catheterization relieves the stimulus.
To correctly perform the eye irrigation, the nurse instills the eye irrigant in which direction?
- A. In the lower conjunctiva toward the corneal surface
- B. From the outer canthus of the eye to the inner canthus
- C. From the nasal corner of the eye toward the temple
- D. From the margins of the eyelashes to the folds of the lids
Correct Answer: C
Rationale: Instilling irrigant from the inner canthus to the outer canthus follows the natural flow of tears, preventing contamination.
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.