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The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.
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When preparing the client for an EEG, which nursing action is most appropriate?
- A. Administer a sedative 1 hour before the test.
- B. Withhold food and water after midnight on the day of the test.
- C. Assist with shampooing the client's hair.
- D. Take the client's blood pressure while lying and sitting.
Correct Answer: C
Rationale: Shampooing the client's hair ensures a clean scalp, improving electrode contact for an accurate EEG.
The nurse is caring for the client who has limited intake due to dysphagia following an ischemic stroke. Which serum laboratory result should the nurse review to verify that the client is dehydrated?
- A. Elevated serum creatinine
- B. Elevated blood urea nitrogen
- C. Decreased hemoglobin
- D. Decreased prealbumin
Correct Answer: B
Rationale: The serum creatinine is elevated with renal insufficiency or renal failure. The BUN is elevated when the client is dehydrated due to the lack of fluid volume to excrete waste products. The Hgb is decreased with blood loss or anemia from nutritional deficiencies, not with dehydration. A decreased prealbumin indicates a nutritional deficiency.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
- A. The assistant places a gait belt around the client's waist prior to ambulating.
- B. The assistant places the client on the back with the client's head to the side.
- C. The assistant places a hand under the client's right axilla to move up in bed.
- D. The assistant praises the client for attempting to perform ADLs independently.
Correct Answer: C
Rationale: Placing a hand under the axilla (C) to move a client with right-sided paralysis risks shoulder subluxation or injury to the weak side. A gait belt (A) is appropriate for safe ambulation, positioning with head to the side (B) prevents aspiration, and praising independence (D) is therapeutic.
Which intervention is priority for a client with AIDS dementia complex experiencing agitation?
- A. Administer a sedative as prescribed.
- B. Provide a quiet, low-stimulus environment.
- C. Restrain the client to prevent injury.
- D. Encourage group activities to distract the client.
Correct Answer: B
Rationale: A quiet, low-stimulus environment reduces agitation in clients with AIDS dementia complex by minimizing sensory overload.
Because carbamazepine (Tegretol) can cause liver dysfunction, the client's discharge plan should include instructions to report which symptom?
- A. Unusual bleeding
- B. Yellowing of the skin
- C. Cloudy urine
- D. Mottled skin
Correct Answer: B
Rationale: Yellowing of the skin (jaundice) indicates potential liver dysfunction, a known side effect of carbamazepine.