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The nurse writes the nursing diagnosis 'altered body temperature related to damaged temperature regulating mechanism' for a client with a head injury. Which would be the most appropriate goal?
- A. Administer acetaminophen (Tylenol) for elevated temperature.
- B. The client's temperature will remain less than 100°F.
- C. Maintain the hypothermia blanket at 99°F for 24 hours.
- D. The basal metabolic temperature will fluctuate no more than two (2) degrees.
Correct Answer: B
Rationale: The goal for altered body temperature is to maintain a normal range, such as less than 100°F (B). Administering medication (A) is an intervention, hypothermia blanket (C) is specific, and basal fluctuation (D) is vague.
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The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first?
- A. Elevate the head of the bed 30 degrees.
- B. Administer oxygen via nasal cannula.
- C. Assess the client’s lung sounds.
- D. Obtain a pulse oximeter reading.
Correct Answer: B
Rationale: Dyspnea in ALS indicates respiratory distress. Administering oxygen (B) addresses hypoxia immediately. Elevating HOB (A), assessing lung sounds (C), and pulse oximetry (D) follow to support respiratory status.
The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?
- A. Explain that this procedure is not painful.
- B. Premedicate the client with a benzodiazepine drug.
- C. Instruct the client to shave all facial hair.
- D. Tell the client it will cause him to see 'floaters.'
Correct Answer: A
Rationale: Explaining that the EEG is painless (A) reduces anxiety. Benzodiazepines (B) are not routine, shaving (C) is unnecessary, and floaters (D) are not associated.
The client has undergone a craniotomy for a brain tumor. Which data indicate a complication of this surgery?
- A. The client complains of a headache at '3' to '4' on a 1-to-10 scale.
- B. The client has an intake of 1,000 mL and an output of 3,500 mL.
- C. The client complains of a raspy, sore throat.
- D. The client experiences dizziness when trying to get up too quickly.
Correct Answer: B
Rationale: Significant output (3,500 mL) compared to intake (1,000 mL, B) suggests diabetes insipidus, a complication of craniotomy due to pituitary dysfunction. Mild headache (A), sore throat (C), and orthostatic dizziness (D) are less concerning.
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
The nurse is assisting the client who sustained a C5 SCI to cough using the quad coughing technique. The nurse correctly demonstrates quad coughing with which actions? Select all that apply.
- A. Places a suction catheter in the client’s oral cavity to stimulate the cough reflex
- B. Puts hands on the upper abdomen, has client inhale, pushes upward during a cough
- C. Cups the hands and percusses the client’s anterior, lateral, and posterior lung fields
- D. Hyperoxygenates the client by using a resuscitation bag to deliver 100% oxygen
- E. Elevates the head of the bed to a high Fowler’s position if the client is sitting in bed
Correct Answer: B,E
Rationale: Stimulating a cough with a suction catheter is not associated with the quad cough technique, and it may cause regurgitation. The nurse’s hand placement and pushing upward during a cough help to overcome the impaired diaphragmatic function that occurs with a C5 SCI. Cupping the hands and percussing the lung fields is a technique to loosen secretions but is not the quad coughing technique. Hyperoxygenating the client is a measure to prevent hypoxia associated with suctioning but is not included in the quad coughing technique. Elevating the head of the bed will promote lung expansion, thus enabling a stronger cough.