Nokea
The nurse writes the problem 'high risk for impaired skin integrity' for the client with an L5-6 spinal cord injury. Which intervention should the nurse include in the plan of care?
- A. Perform active range-of-motion exercise.
- B. Massage the legs and trochanters every shift.
- C. Arrange for a Roho cushion in the wheelchair.
- D. Apply petroleum-based lotion to the extremities.
Correct Answer: C
Rationale: A Roho cushion (C) reduces pressure ulcers in SCI patients. Active ROM (A) is not possible, massage (B) risks skin breakdown, and petroleum lotion (D) is not specific.
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Which teaching topics should the nurse cover before discharge? Select all that apply.
- A. Dietary restrictions
- B. Avoiding heavy lifting
- C. Staying out of bright sunlight
- D. Missed doses
- E. Bruising or blood in urine
- F. Need for frequent laboratory work
Correct Answer: A,D,E,F
Rationale: Warfarin requires dietary consistency, instructions on missed doses, monitoring for bleeding (bruising/blood in urine), and frequent INR checks.
The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?
- A. Do you have trouble hearing?'
- B. Are you allergic to any type of dairy products?'
- C. Have you eaten anything in the last eight (8) hours?'
- D. Are you uncomfortable in closed spaces?'
Correct Answer: D
Rationale: MRI scans require lying still in a confined space, so assessing for claustrophobia (D) is critical to ensure patient safety and comfort. Hearing issues (A), dairy allergies (B), and recent eating (C) are not relevant to MRI preparation.
The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first?
- A. Schedule a STAT Magnetic Resonance Imaging of the brain.
- B. Call a Code STROKE.
- C. Notify the health-care provider (HCP).
- D. Have the client swallow a glass of water.
Correct Answer: B
Rationale: Symptoms suggest an acute stroke, requiring immediate activation of a Code STROKE (B) to expedite diagnosis and treatment. MRI (A), notifying HCP (C), and swallowing tests (D) follow protocol activation.
Which finding in a client post-stroke indicates a need for immediate intervention?
- A. Blood pressure of 180/100 mmHg
- B. Mild weakness in the right arm
- C. Difficulty finding words
- D. Fatigue after physical therapy
Correct Answer: A
Rationale: Severe hypertension post-stroke increases the risk of hemorrhage or further brain injury, requiring immediate intervention.
The nurse in the ED documents that the newly admitted client is 'postictal upon transfer.' What did the nurse observe?
- A. Yellowing of the skin due to a liver condition
- B. Drowsy or confused state following a seizure
- C. Severe itching of the eyes from an allergic reaction
- D. Abnormal sensations including tingling of the skin
Correct Answer: B
Rationale: Jaundice and icterus are terms for yellowing of the skin. The client had experienced a tonic-clonic seizure recently and is now in a state of deep relaxation and is breathing quietly. During this period the client may be unconscious or awaken gradually, but is often confused and disoriented. Often the client is amnesic regarding the seizure. Pruritus is a term for itching. Paresthesia is the term for abnormal sensations such as tingling and burning of the skin.