Nokea
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- A. Assess the client's level of consciousness.
- B. Organize onlookers to remove the client from the lake.
- C. Perform a head-to-toe assessment to determine injuries.
- D. Stabilize the client's cervical spine.
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (A), organizing removal (B), or performing a full assessment (C) follows.
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An older adult with PD is prescribed levodopa and carbidopa. What information should the nurse include when teaching the client and spouse?
- A. The client has an increased risk for falls.
- B. The client should stop taking multiple vitamins.
- C. The medication should not be taken with food.
- D. The medication has very few adverse effects.
Correct Answer: A
Rationale: When first taking levodopa/carbidopa (Sinemet), the client is likely to experience dizziness and orthostatic hypotension due to the dopamine agonist properties. The client and spouse must be alerted about the increased risk for falls. Levodopa/carbidopa can be taken with multiple vitamins. Levodopa/carbidopa can be taken with food to decrease GI upset. There are many, not few, adverse effects associated with levodopa/carbidopa, including involuntary movements, anxiety, memory loss, blurred vision, and mydriasis.
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
- A. The client will maintain body weight within two (2) pounds.
- B. The client will execute an advance directive.
- C. The client will be able to perform three (3) ADLs with assistance.
- D. The client will verbalize feeling of loss by the end of the shift.
Correct Answer: C
Rationale: A realistic goal for self-care deficit is performing ADLs with assistance (C), addressing functional limitations due to the tumor. Weight maintenance (A), advance directives (B), and verbalizing loss (D) are not directly related to self-care.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
- A. A subcutaneous anticoagulant.
- B. An intravenous osmotic diuretic.
- C. An oral anticonvulsant.
- D. An oral proton pump inhibitor.
Correct Answer: A
Rationale: Subcutaneous anticoagulants (A) increase bleeding risk in head injury patients, where intracranial hemorrhage is a concern, and should be questioned. Osmotic diuretics (B) reduce ICP, anticonvulsants (C) prevent seizures, and proton pump inhibitors (D) protect against stress ulcers.
The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially?
- A. Right hemiparesis
- B. Expressive aphasia
- C. Poor impulse control
- D. Tetraplegia
Correct Answer: C
Rationale: A stroke affecting the right hemisphere may produce left, not right hemiparesis. Motor fibers in the brain cross over in the medulla before entering the spinal column. This client may or may not have aphasia because the center for language is located on the left side of the brain in 75% to 80% of the population; this client had a stroke involving the right hemisphere. Even though the client may have expressive aphasia, it is more important to assess for poor impulse control due to the risk for injury. The client with a stroke affecting the right side of the brain often exhibits impulsive behavior and is unaware of the neurological deficits. Poor impulse control increases the client’s risk for injury. Tetraplegia (quadriplegia) is associated with an SCI; tetraplegia usually does not occur from a stroke.