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When a client is injured during a seizure, which fact is most important to document on the incident (accident) report to reduce the risk of liability?
- A. The client was assigned to a licensed nurse.
- B. The signal cord was within the client's reach.
- C. The client's vital signs had been stable.
- D. The client was last observed reading.
Correct Answer: B
Rationale: Documenting that the signal cord was within reach indicates that safety measures were in place, reducing liability.
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How can the nurse best help the client deal with personal fears at this time?
- A. Encourage the client to verbalize feelings.
- B. Provide a detailed explanation of the disease progression.
- C. Tell the client about physical assessment findings.
- D. Explain that the disease may become periodically acute.
Correct Answer: A
Rationale: Encouraging verbalization of feelings helps the client process fears and promotes emotional coping during an MS exacerbation.
Which finding is considered to be one of the warning signs of developing Alzheimer's disease?
- A. Difficulty performing familiar tasks.
- B. Problems with orientation to date, time, and place.
- C. Having problems focusing on a task.
- D. Atherosclerotic changes in the vessels.
Correct Answer: A
Rationale: Difficulty performing familiar tasks (A) is an early Alzheimer’s sign due to cognitive decline. Orientation issues (B) occur later, focus problems (C) are nonspecific, and atherosclerosis (D) is unrelated.
The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.
Before discharge, the nurse instructs the client about administering subcutaneous injections and correctly explains the client should rotate injections between which two areas?
- A. Thighs and hips
- B. Forearms and hips
- C. Thighs and abdomen
- D. Abdomen and buttocks
Correct Answer: C
Rationale: Rotating injections between the thighs and abdomen minimizes tissue damage and ensures consistent absorption.
Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
- A. Complete neurovascular examinations every eight (8) hours.
- B. Maintain accurate intake and output at the end of each shift.
- C. Assess the client’s symptoms to determine if there is improvement.
- D. Administer intravenous fluids while assessing for overload.
Correct Answer: D
Rationale: IV fluids (D) support hydration in West Nile virus while monitoring for overload prevents complications. Neurovascular exams (A) are less relevant, intake/output (B) is routine, and symptom assessment (C) is nursing-driven.