Nokea
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.
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The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?
- A. Positive Babinski’s sign and peripheral paresthesia.
- B. Negative Chvostek’s sign and facial tingling.
- C. Positive Kernig’s sign and nuchal rigidity.
- D. Negative Trousseau’s sign and nystagmus.
Correct Answer: C
Rationale: Kernig’s sign (pain with leg extension) and nuchal rigidity (C) are hallmark signs of bacterial meningitis due to meningeal irritation. Other options include unrelated or less specific findings.
When the client is observed wandering about the facility, the nurse modifies the client's care plan to provide for safety. Which nursing intervention is most appropriate at this time?
- A. Keep the client confined to the room.
- B. Attach an identity tag to the client's clothes.
- C. Lock all the outside doors in the facility.
- D. Make sure the client knows the location of the facility.
Correct Answer: B
Rationale: An identity tag helps ensure the client can be identified and returned safely if they wander, promoting safety without restricting freedom.
The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest 'Lou Gehrig’s' disease. Which is the nurse’s most appropriate response?
- A. “Muscle weakness can occur from working too much. Avoid thinking the worst.”
- B. “Tell me what has you thinking that you might have Lou Gehrig’s disease.”
- C. “Have you been having trouble remembering things along with this weakness?”
- D. “That is a good question. We will be doing tests to figure out what is going on.”
Correct Answer: B
Rationale: There is no information that the client is working too much. Telling the client to avoid thinking the worst belittles the client’s concern. This is the most appropriate response because it focuses on the client’s concern, encourages verbalization, and solicits more information. ALS (Lou Gehrig’s disease) is a degenerative disease that affects the motor system and does not have a dementia component; thus, a question about memory is inappropriate. This response does not take the client seriously and does not address the client’s concern.
The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, 'Why not try chemotherapy first? It has helped my other tumors.' The nurse’s response is based on which scientific rationale?
- A. Chemotherapy is only used as a last resort in caring for clients with brain tumors.
- B. The blood-brain barrier prevents medications from reaching the brain.
- C. Radiation therapy will have fewer side effects than chemotherapy.
- D. Metastatic tumors become resistant to chemotherapy and it becomes useless.
Correct Answer: B
Rationale: The blood-brain barrier (B) limits chemotherapy penetration into the brain, making radiation more effective for brain metastases. Chemotherapy is used in some cases (A), radiation side effects vary (C), and resistance (D) is not universally true.
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.