Nokea
The nurse is caring for the older adult client with normal pressure hydrocephalus (NPH). Which treatment measure should the nurse anticipate?
- A. Carotid endarterectomy
- B. Ventriculoperitoneal shunt
- C. Insertion of a lumbar drain
- D. Anticonvulsant medications
Correct Answer: B
Rationale: A carotid endarterectomy involves removal of plaque from the carotid artery. NPH is treated with the placement of a permanent shunt in a lateral ventricle of the brain to the peritoneal cavity. The excess CSF drains into the peritoneal cavity. A lumbar drain can be used to remove CSF with disorders that increase CSF in the subarachnoid space in the lumbar area; this does not remain permanently. Anticonvulsant medications are used to treat seizures.
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The nurse arrives at the scene of a motor-vehicle accident and the car is leaking gasoline. The client is in the driver's seat of the car complaining of not being able to move the legs. Which actions should the nurse implement? List in order of priority.
- A. Move the client safely out of the car.
- B. Assess the client for other injuries.
- C. Stabilize the client's neck.
- D. Notify the emergency medical system.
- E. Place the client in a functional anatomical position.
Correct Answer: C,B,A,D,E
Rationale: Stabilize the client’s neck (C): Prevents spinal injury. 2. Assess for other injuries (B): Identifies life-threatening issues. 3. Move the client safely (A): Removes from gasoline danger. 4. Notify EMS (D): Ensures professional help. 5. Place in anatomical position (E): Least urgent.
When the nurse observes that the client has difficulty swallowing the capsule of medication, which action is best to take?
- A. Soak the capsule in water until soft.
- B. Tell the client to chew the capsule.
- C. Moisten the capsule in the client's mouth.
- D. Offer water before giving the capsule.
Correct Answer: D
Rationale: Offering water before giving the capsule aids swallowing without altering the medication's integrity.
Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
Before requesting the clear liquids prescribed by the physician, which assessment information is essential for the nurse to know?
- A. The client's ability to raise the head
- B. The client's preferences of clear liquids
- C. Whether the client's bowel sounds have returned
- D. The client's ability to swallow effectively
Correct Answer: D
Rationale: Assessing the ability to swallow ensures safety when initiating oral intake post-craniotomy.
Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)?
- A. Diabetes mellitus type 2 (DM 2).
- B. Seizure activity.
- C. Syndrome of inappropriate antidiuretic hormone (SIADH).
- D. Cushing's disease.
Correct Answer: C
Rationale: TBI can damage the pituitary, causing SIADH (C), leading to fluid retention and hyponatremia. DM2 (A) is unrelated, seizures (B) are neurological, and Cushing’s (D) is less common post-TBI.