Nokea
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority?
- A. Maintaining accurate records of intake and output
- B. Maintaining a patent airway
- C. Inserting a nasogastric (NG) tube as ordered
- D. Providing appropriate pain control
Correct Answer: B
Rationale: Maintaining a patent airway is critical for an unconscious patient to ensure oxygenation and prevent aspiration. Other interventions, while important, are secondary to airway management.
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The nurse caring for a patient in a persistent vegetative state is regularly assessing for potential complications. Complications of neurologic dysfunction for which the nurse should assess include which of the following? Select all that apply.
- A. Contractures
- B. Hemorrhage
- C. Pressure ulcers
- D. Venous thromboembolism
- E. Pneumonia
Correct Answer: A,C,D,E
Rationale: Immobility in a vegetative state increases risks for contractures, pressure ulcers, DVT, and pneumonia. Hemorrhage is not a common complication of decreased LOC.
A neurologic nurse is reviewing seizures with a group of staff nurses. How should this nurse best describe the cause of a seizure?
- A. Sudden electrolyte changes throughout the brain
- B. A dysrhythmia in the peripheral nervous system
- C. A dysrhythmia in the nerve cells in one section of the brain
- D. Sudden disruptions in the blood flow throughout the brain
Correct Answer: C
Rationale: Seizures result from a dysrhythmia in a specific brain region's nerve cells. Electrolyte changes, peripheral nervous system issues, or blood flow disruptions are not primary causes.
A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety?
- A. Place the patient in a side-lying position.
- B. Pad the patients bed rails.
- C. Administer antianxiety medications as ordered.
- D. Reassure the patient and family members.
Correct Answer: B
Rationale: A side-lying position prevents aspiration of secretions post-seizure. Padding rails, antianxiety drugs, or reassurance are secondary to airway safety.
A nurse is admitting a patient with a severe migraine headache and a history of acute coronary syndrome. What migraine medication would the nurse question for this patient?
- A. Rizatriptan (Maxalt)
- B. Naratriptan (Amerge)
- C. Sumatriptan succinate (Imitrex)
- D. Zolmitriptan (Zomig)
Correct Answer: C
Rationale: Sumatriptan and other triptans can cause chest pain and are contraindicated in ischemic heart disease. All listed medications are triptans, but sumatriptan is specifically noted for this risk.
The nurse is caring for a patient who is postoperative following a craniotomy. When writing the plan of care, the nurse identifies a diagnosis of deficient fluid volume related to fluid restriction and osmotic diuretic use. What would be an appropriate intervention for this diagnosis?
- A. Change the patients position as indicated.
- B. Monitor serum electrolytes.
- C. Maintain NPO status.
- D. Monitor arterial blood gas (ABG) values.
Correct Answer: B
Rationale: Monitoring serum electrolytes adjusts fluid and electrolyte therapy in patients with deficient fluid volume post-craniotomy. Positioning, NPO status, and ABG monitoring do not directly address this diagnosis.