Nokea
When changing the client's position postoperatively, which nursing action is best?
- A. Raise the client with a mechanical lift.
- B. Logroll the client from side to side.
- C. Have the client flex the knees and lift.
- D. Pull the client's arms and then the legs.
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.
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The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
- A. The client will return to work within six (6) months.
- B. The client is able to focus and stay on task for 10 minutes.
- C. The client will be able to dress self without assistance.
- D. The client will regain bowel and bladder control.
Correct Answer: B
Rationale: Cognitive deficits post-TBI may limit complex tasks. Focusing for 10 minutes (B) is a realistic short-term goal to build cognitive endurance. Returning to work (A) may be unrealistic within 6 months, dressing independently (C) requires motor and cognitive skills, and bowel/bladder control (D) may be affected by physical deficits.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.
Which goal is most realistic for a client diagnosed with Parkinson's disease?
- A. To reverse the symptoms and cure the disease
- B. To remove the symptoms of the disease process
- C. To maintain optimal muscle and motor function
- D. To prepare for a progressive terminal disease
Correct Answer: C
Rationale: Maintaining optimal muscle and motor function is realistic, as Parkinson's is progressive but manageable with treatment.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
- A. Obtain a rubber mat to place under the dinner plate.
- B. Purchase a long-handled bath sponge for showering.
- C. Purchase clothes with Velcro closure devices.
- D. Obtain a raised toilet seat for the client's bathroom.
Correct Answer: B,C,D
Rationale: Generalized weakness post-stroke affects mobility and self-care. A long-handled bath sponge (B) aids bathing, Velcro clothes (C) simplify dressing, and a raised toilet seat (D) facilitates safe toileting. A rubber mat (A) is less relevant to generalized weakness.
The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly?
- A. Alzheimer’s disease.
- B. Parkinson’s disease (PD).
- C. Cerebral Vascular Accident (CVA, stroke).
- D. Brain atrophy due to aging.
Correct Answer: C
Rationale: Stroke (CVA, C) is the leading cause of seizures in the elderly due to brain tissue damage. Alzheimer’s (A) and Parkinson’s (B) may cause seizures but are less common, and brain atrophy (D) is not a primary cause.