Nokea
The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
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The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?
- A. Muscle atrophy and flaccidity.
- B. Fatigue and malnutrition.
- C. Slurred speech and dysphagia.
- D. Weakness and paralysis.
Correct Answer: C
Rationale: Slurred speech and dysphagia (C) are early ALS signs due to bulbar muscle involvement. Atrophy/flaccidity (A) and weakness/paralysis (D) occur later, and fatigue/malnutrition (B) are nonspecific.
Which intervention is most appropriate for a client with multiple sclerosis experiencing fatigue?
- A. Schedule activities in the late afternoon.
- B. Encourage short, frequent rest periods.
- C. Administer caffeine supplements.
- D. Increase physical therapy sessions.
Correct Answer: B
Rationale: Short, frequent rest periods help manage fatigue in multiple sclerosis by conserving energy.
The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving?
- A. The current GSC rating is 3.
- B. The current GSC rating is 9.
- C. The current GSC rating is 10.
- D. The current GSC rating is 12.
Correct Answer: D
Rationale: A GCS of 12 (D) is higher than 10, indicating improved neurological status. Scores of 3 (A) or 9 (B) indicate worsening, and 10 (C) shows no change.
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.
The client is prescribed a loading dose of phenytoin of 15 mg/kg IV for seizure activity, then 100 mg IV tid. The client weighs 198 lb. What dose in mg should the nurse administer for the loading dose of phenytoin?
- A. 1350 mg IV
Correct Answer: 1350
Rationale: 198 lb = 90 kg; (198 ÷ 2.2 = 90 kg; 90 x 15 = 1350) The nurse should administer 1350 mg phenytoin (Dilantin).