Nokea
The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:
- A. XII (hypoglossal)
- B. X (vagus)
- C. IX (glossopharyngeal)
- D. VII (facial)
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.
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The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client? Select all that apply.
- A. maintain normal toileting routines
- B. minimize visitation so that the client may rest
- C. evaluate the client's medications for side effects
- D. keep familiar items such as family pictures near the bedside
- E. use calendars and clocks to orient the client to the date and time
- F. place the client in a room near the end of the hall to minimize noise
Correct Answer: A,C,D,E
Rationale: Toileting routines, medication review, familiar items, and calendars/clocks promote orientation. Minimizing visitation may isolate the client, and room placement is less relevant.
A postoperative client whose oxygen saturation has been stable at 96% to 98% suddenly shows a drop to 80%. What initial response is most indicated?
- A. Notify physician.
- B. Administer oxygen.
- C. Assess client and reposition pulse oximeter.
- D. Collect an arterial specimen for ABGs.
Correct Answer: C
Rationale: Assessing and repositioning the pulse oximeter (C) checks for false readings first. Oxygen (B), notifying physician (A), or ABGs (D) follow if needed.
A 4-year-old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of 12 Gm
- B. A platelet count of 200,000
- C. A white blood cell count of 16,000
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white blood cell count of 16,000 suggests infection or inflammation, which should be reported before surgery.
The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.
A client tells the nurse that she takes St. John's wort (hypericum perforatum) three times a day for mild depression. The nurse should tell the client that:
- A. St. John's wort seldom relieves depression.
- B. She should avoid eating aged cheese.
- C. Skin reactions increase with the use of sunscreen.
- D. The herbal is safe to use with other antidepressants.
Correct Answer: C
Rationale: St. John's wort can cause photosensitivity, increasing the risk of skin reactions, so sunscreen use is recommended, not avoided.