Nokea
To correctly perform the eye irrigation, the nurse instills the eye irrigant in which direction?
- A. In the lower conjunctiva toward the corneal surface
- B. From the outer canthus of the eye to the inner canthus
- C. From the nasal corner of the eye toward the temple
- D. From the margins of the eyelashes to the folds of the lids
Correct Answer: C
Rationale: Instilling irrigant from the inner canthus to the outer canthus follows the natural flow of tears, preventing contamination.
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The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
Which laboratory result is most concerning for a client with suspected meningitis?
- A. Elevated white blood cell count
- B. Decreased glucose in cerebrospinal fluid
- C. Normal protein levels in cerebrospinal fluid
- D. Increased red blood cell count in blood
Correct Answer: B
Rationale: Decreased glucose in cerebrospinal fluid is a hallmark of bacterial meningitis, indicating infection and requiring urgent treatment.
The nurse is conducting a support group for clients diagnosed with Parkinson’s disease and their significant others. Which information regarding psychosocial needs should be included in the discussion?
- A. The client should discuss feelings about being placed on a ventilator.
- B. The client may have rapid mood swings and become easily upset.
- C. Pill-rolling tremors will become worse when the medication is wearing off.
- D. The client may automatically start to repeat what another person says.
Correct Answer: B
Rationale: Rapid mood swings and emotional upset (B) are common in Parkinson’s due to dopamine fluctuations, addressing psychosocial needs. Ventilator discussions (A) are irrelevant, tremors (C) are physical, and echolalia (D) is not typical.
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.
Which home care suggestion is best for promoting the mobility of the client with a spinal cord injury?
- A. Rent or buy a conventional hospital bed.
- B. Build a wheelchair ramp to the door.
- C. Apply for a handicapped parking sticker.
- D. Provide a raised toilet seat with grab bars.
Correct Answer: B
Rationale: A wheelchair ramp enhances home accessibility, significantly improving mobility for a client with a spinal cord injury.