Nokea
The nurse writes the diagnosis 'risk for injury related to impaired balance' for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?
- A. Provide information about vertigo and its treatment.
- B. Assess for level and type of diversional activity.
- C. Assess for visual acuity and proprioceptive deficits.
- D. Refer the client to a support group and counseling.
Correct Answer: C
Rationale: Assessing visual and proprioceptive deficits identifies factors contributing to vertigo-related falls, enhancing safety. Information, activities, and referrals are secondary.
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The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.
The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol?
- A. Deep tendon reflexes
- B. Urine output
- C. Level of orientation
- D. Pulse rate
Correct Answer: B
Rationale: Mannitol is a diuretic, so monitoring urine output is critical to assess its effectiveness and prevent dehydration.
The elderly male client tells the nurse, 'My wife says her cooking hasn't changed, but it is bland and tasteless.' Which response by the nurse is most appropriate?
- A. Would you like me to talk to your wife about her cooking?
- B. Taste buds change with age, which may be why the food seems bland.
- C. This happens because the medications sometimes cause a change in taste.
- D. Why don't you barbecue food on a grill if you don't like your wife's cooking?
Correct Answer: B
Rationale: Age-related taste bud decline reduces taste perception, a common issue in the elderly. Talking to the wife, blaming medications, or suggesting grilling are less appropriate.
The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child?
- A. Pull the pinna upward only to instill the eardrops.
- B. Pull the pinna to a neutral position to instill the eardrops.
- C. Pull the pinna upward and backward prior to instilling the drops.
- D. Pull the pinna downward and forward to instill the drops.
Correct Answer: D
Rationale: For children under 3, pulling the pinna down and back straightens the ear canal; for older children like a 6-year-old, down and back is still appropriate. Upward or neutral pulls are incorrect.
The client following removal of a right-sided acoustic neuroma by a translabyrinthine approach calls the nurse to report pain. The nurse finds that the client has new-onset right-sided facial drooping and numbness. Place the nurse's actions in priority order.
- A. Close the client's right eye and place a patch over it.
- B. Assess the operative incision site and assess the arms for drift.
- C. Contact the stroke team and the HCP.
- D. Medicate the client for pain unless contraindicated.
Correct Answer: B,C,D,A
Rationale: Assess the incision and arms for drift first (B), then contact the stroke team and HCP for possible complications (C), medicate for pain (D), and finally patch the eye due to inability to close it (A).