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The nurse is working with several clients in a substance abuse clinic. Client A tells the nurse that another client, Client B, has 'started using again.' Which action should the nurse implement?
- A. Tell Client A the nurse cannot discuss Client B with him.
- B. Find out how Client A got this information.
- C. Inform the HCP that Client B is using again.
- D. Get in touch with Client B and have the client come to the clinic.
Correct Answer: D
Rationale: Allegations of relapse require direct assessment. Contacting Client B (D) allows the nurse to evaluate the situation respectfully. Discussing Client B with Client A (A) or probing Client A (B) breaches confidentiality, and informing the HCP (C) is premature without verification.
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Which home care suggestion is best for promoting the mobility of the client with a spinal cord injury?
- A. Rent or buy a conventional hospital bed.
- B. Build a wheelchair ramp to the door.
- C. Apply for a handicapped parking sticker.
- D. Provide a raised toilet seat with grab bars.
Correct Answer: B
Rationale: A wheelchair ramp enhances home accessibility, significantly improving mobility for a client with a spinal cord injury.
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 asks why fluids are being restricted, which explanation by the nurse is best?
- A. Large amounts of fluid may contribute to vomiting.'
- B. The kidneys need to conserve fluid output.'
- C. Fluid restriction reduces the volume in the cranium.'
- D. The prescribed volume is sufficient for relieving thirst.'
Correct Answer: C
Rationale: Fluid restriction reduces intracranial volume, minimizing the risk of increased intracranial pressure post-craniotomy.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
- A. Administer a nonnarcotic analgesic.
- B. Prepare for STAT magnetic resonance imaging (MRI).
- C. Start an intravenous infusion with D5W at 100 mL/hr.
- D. Complete a neurological assessment.
Correct Answer: D
Rationale: A severe headache in a stroke patient may indicate complications like hemorrhagic transformation or increased intracranial pressure. A neurological assessment (D) is the first step to evaluate the cause and guide further actions. Analgesics (A) may mask symptoms, MRI (B) requires assessment first, and IV fluids (C) are not urgent.
The nurse is caring for the client who has severe craniocerebral trauma. Which finding indicates that the client is developing DI?
- A. Blood glucose level at 230 mg/dL
- B. Urinary output 1500 mL over 4 hours
- C. Urine specific gravity at 1.042
- D. Somnolent when previously alert
Correct Answer: B
Rationale: Elevated glucose levels are not associated with DI. The lack of ADH that occurs in DI results in excreting a large amount of pale, dilute urine. The urine of clients with DI is very dilute and therefore has a very low, not high, specific gravity. Decrease in level of consciousness is not directly associated with DI but rather with craniocerebral swelling or bleeding from the trauma.