Nokea
The nurse performs the Glasgow Coma Scale while assessing a client with a brainstem injury. Which additional interventions should the nurse be prepared to implement? Select all that apply.
- A. Assisting with arterial blood gases
- B. Assisting with a lumbar puncture
- C. Assessing cranial nerve functioning
- D. Assessing respiratory rate and rhythm
- E. Assessing pulmonary wedge pressure
- F. Assessing cognitive abilities, including memory
Correct Answer: C,D
Rationale: Assessment should be specific to the area of the brain involved. Assessing the respiratory status and cranial nerve function is a critical component of the assessment process in a client with a brainstem injury because the respiratory center is located in the brainstem. Options 1, 2, 5, and 6 are not necessary based on the data in the question.
You may also like to solve these questions
A client's telemetry monitor displays ventricular tachycardia. Upon reaching the client's bedside, which action should the nurse take first?
- A. Call a code.
- B. Prepare for cardioversion.
- C. Prepare to defibrillate the client.
- D. Check the client's level of consciousness.
Correct Answer: D
Rationale: Determining unresponsiveness is the first assessment action to take. When a client is in ventricular tachycardia, there is a significant decrease in cardiac output. However, assessing for unresponsiveness helps determine whether the client is affected by the decreased cardiac output. If the client is unconscious, then cardiopulmonary resuscitation is initiated.
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
- A. Hypovolemia
- B. Hypoglycemia
- C. Mood disturbances
- D. Deficient fluid volume
Correct Answer: C
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess), and hypertension.
The nurse is reviewing the results of a sweat test performed on a child diagnosed with cystic fibrosis (CF). Which finding should the nurse identify as supporting this diagnosis?
- A. An evening sweat potassium concentration greater than 60 mEq/L
- B. A sweat chloride concentration that is consistently greater 60 mEq/L
- C. An early morning sweat chloride concentration of less than 40 mEq/L
- D. A sweat potassium concentration that is consistently less than 40 mEq/L
Correct Answer: B
Rationale: Cystic fibrosis is a chronic multisystem disorder characterized by exocrine gland dysfunction. A consistent finding of abnormally high chloride concentrations in the sweat is a unique characteristic of CF. Normally the sweat chloride concentration is less than 40 mEq/L. A sweat chloride concentration greater than 60 mEq/L is diagnostic of CF. Potassium concentration is unrelated to the sweat test.
The nurse provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.
- A. If I am ill, I should skip my daily dose.
- B. If I overeat, I will double my dosage of medication.
- C. Oral agents are effective in managing type 2 diabetes.
- D. If I become pregnant, I will discontinue my medication.
- E. Oral hypoglycemic medications will cause my urine to turn orange.
- F. My medications are used to manage my diabetes along with diet and exercise.
Correct Answer: A,B,D,E
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.
Acetylsalicylic acid (aspirin) is prescribed for a client diagnosed with coronary artery disease before a percutaneous transluminal coronary angioplasty (PTCA). The nurse administers the medication understanding that it is prescribed for what purpose?
- A. Relieve postprocedure pain.
- B. Prevent thrombus formation.
- C. Prevent postprocedure hyperthermia.
- D. Prevent inflammation of the puncture site.
Correct Answer: B
Rationale: Before PTCA, the client is usually given an anticoagulant, commonly aspirin, to help reduce the risk of occlusion of the artery during the procedure because the aspirin inhibits platelet aggregation.