Nokea
When documenting a seizure, which information is most important to include initially?
- A. The time the seizure started
- B. The duration of the seizure
- C. The client's mood just before the seizure
- D. The client's comments after the seizure
Correct Answer: A
Rationale: Documenting the time the seizure started is critical for tracking seizure patterns and guiding treatment.
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Which assessment finding post-craniotomy requires immediate reporting to the physician?
- A. Clear drainage from the incision
- B. Pain controlled with analgesics
- C. Stable vital signs
- D. Mild swelling at the incision site
Correct Answer: A
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a serious complication requiring immediate intervention.
When the nursing team plans the care of a client with Guillain-Barré syndrome, which assessment finding most accurately determines whether the client is developing ineffective breathing?
- A. Respiratory rate is 24.
- B. Skin is flushed.
- C. Activity is decreased.
- D. Pulse oximetry reading is 82%.
Correct Answer: D
Rationale: A pulse oximetry reading of 82% indicates significant hypoxemia, suggesting ineffective breathing, which is a critical concern in Guillain-Barré syndrome due to potential respiratory muscle weakness.
Which environmental modifications should the nurse implement? Select all that apply.
- A. Keep the room dark and quiet.
- B. Lower the bed to the lowest position.
- C. Keep the side rails up and padded.
- D. Provide soft, soothing music.
- E. Ensure a warm, well-lit room.
- F. Make sure suction equipment is available.
Correct Answer: B,C,F
Rationale: Lowering the bed, padding side rails, and ensuring suction equipment availability reduce injury risk and manage complications during a seizure.
When the nursing team discusses the client's plan of care, which has the highest priority?
- A. Teaching the client about prevention of skin breakdown
- B. Strengthening the client's upper body muscles
- C. Confronting the client's denial of the prognosis
- D. Letting the client verbalize about the accident
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
The client being monitored while receiving tissue plasminogen activator (tPA) following an ischemic stroke opens both eyes spontaneously, mumbles inappropriate words in response to orientation questions, has no ability to move any extremities, and has decerebrate posturing in response to nailbed pressure. Based on the chart illustrated, what is the client’s Glasgow Coma Scale (GCS) score?
- A. 9 GCS score
Correct Answer: 9
Rationale: Spontaneous eye opening is scored as 4; the best verbal response of inappropriate words is scored as 3, and the best motor response of decerebrate posturing is scored as 2.