Nokea
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
- A. Help the UAP to insert the oral airway in the mouth.
- B. Tell the UAP to stop trying to insert anything in the mouth.
- C. Take no action because the UAP is handling the situation.
- D. Notify the charge nurse of the situation immediately.
Correct Answer: B
Rationale: Inserting objects during a seizure (B) risks injury to the mouth or airway and is contraindicated. The nurse must intervene immediately. Helping the UAP (A) is unsafe, taking no action (C) neglects responsibility, and notifying the charge nurse (D) delays correction.
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Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease)?
- A. Discuss a percutaneous gastrostomy tube.
- B. Explain how a fistula is accessed.
- C. Provide an advance directive.
- D. Refer to a physical therapist for leg braces.
Correct Answer: C
Rationale: ALS is progressive and terminal. Providing an advance directive (C) ensures the client’s wishes are respected early. Gastrostomy (A) is later, fistulas (B) are unrelated, and leg braces (D) are less urgent.
The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially?
- A. Right hemiparesis
- B. Expressive aphasia
- C. Poor impulse control
- D. Tetraplegia
Correct Answer: C
Rationale: A stroke affecting the right hemisphere may produce left, not right hemiparesis. Motor fibers in the brain cross over in the medulla before entering the spinal column. This client may or may not have aphasia because the center for language is located on the left side of the brain in 75% to 80% of the population; this client had a stroke involving the right hemisphere. Even though the client may have expressive aphasia, it is more important to assess for poor impulse control due to the risk for injury. The client with a stroke affecting the right side of the brain often exhibits impulsive behavior and is unaware of the neurological deficits. Poor impulse control increases the client’s risk for injury. Tetraplegia (quadriplegia) is associated with an SCI; tetraplegia usually does not occur from a stroke.
When planning a bowel retraining program for a client with a spinal cord injury, which nursing intervention is most appropriate?
- A. Administering a stool softener twice per week
- B. Encouraging the client to consume a high-fiber diet
- C. Having the client drink two glasses of water every morning
- D. Teaching the client to self-administer daily enemas
Correct Answer: B
Rationale: A high-fiber diet promotes regular bowel movements, which is essential for bowel retraining in spinal cord injury clients.
When the nurse describes the myelogram procedure to the client, which statement is most accurate?
- A. Part of the test involves a lumbar puncture.'
- B. You will be asked to change positions frequently.'
- C. Dye is instilled into a vein in your arm.'
- D. Light anesthesia is administered during the test.'
Correct Answer: A
Rationale: A myelogram involves a lumbar puncture to inject contrast dye into the spinal canal for imaging.
The nurse’s client with a T2 SCI is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse’s interventions in the order that these should be performed.
- A. Elevate the HOB to 90 degrees.
- B. Lower the end of the bed so feet are dependent.
- C. Remove elastic stocking and other constricting devices; assess below the level of injury.
- D. Retake the blood pressure after being upright for 2 to 3 minutes.
- E. Administer a pm prescribed sublingual nifedipine for continued elevated BP.
- F. Perform digital removal of impacted stool (last BM found to be 10 days ago).
- G. Inform the HCP of the incident, measures taken, and client response.
Correct Answer: C,A,B,G,F,E,D
Rationale: Elevate the HOB to 90 degrees. This initial quick action may help lower the client’s BP. Lower the end of the bed so feet are dependent. Placing the feet lower than the head will help decrease blood return and may help lower the BP. Remove elastic stocking and other constricting devices; assess below the level of injury. Anything constricting below the level of injury can be the stimulus that precipitates autonomic dysreflexia. The nurse can assess for other precipitating factors, such as a full bladder, while removing constricting devices. Retake the BP after being upright for 2 to 3 minutes. Elevating the HOB, lowering the feet, and removing constricting devices may have lowered the BP. If not, further interventions are needed. Administer a pm prescribed sublingual nifedipine for continued elevated BP. If the BP remains elevated, the prescribed antihypertensive medication, such as nifedipine (Procardia), should be given next to quickly lower the BP. Perform digital removal of impacted stool (last BM found to be 10 days ago). Digitally removing stool impaction may cause a further spike in BP, so that should be completed after the BP medication is administered. Inform the HCP of the incident, measures taken, and client response. This is last because a pro antihypertensive medication had already been prescribed. Care of the client is priority.