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When implementing this medical order, which nursing action is most appropriate?
- A. Place the cooling blanket on top of the client.
- B. Wrap the cooling blanket in a light cloth cover.
- C. Add normal saline solution to the fluid chamber.
- D. Replace crushed ice periodically as it melts.
Correct Answer: B
Rationale: Wrapping the cooling blanket in a light cloth cover prevents direct skin contact, reducing the risk of thermal injury while allowing effective cooling.
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The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
- A. Social worker.
- B. Chaplain.
- C. Health-care provider.
- D. Occupational therapist.
Correct Answer: A
Rationale: A social worker (A) can connect the family with community resources, financial aid, and support services. Chaplains (B) address spiritual needs, providers (C) focus on medical care, and occupational therapists (D) address functional deficits.
The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client’s history of the injury should the nurse associate with the TBI? Select all that apply.
- A. The client has had no episodes of vomiting after the accident.
- B. The client remembers events before and right after the accident.
- C. The client has had headache and dizziness daily since the accident.
- D. The client has difficulty concentrating and focusing while at work.
- E. The client lost consciousness momentarily at the time of the injury.
Correct Answer: C,D,E
Rationale: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
Which should be the nurse's first intervention with the client diagnosed with Bell's palsy?
- A. Explain that this disorder will resolve within a month.
- B. Tell the client to apply heat to the involved side of the face.
- C. Encourage the client to eat a soft diet.
- D. Teach the client to protect the affected eye from injury.
Correct Answer: D
Rationale: Bell’s palsy impairs eye closure, risking corneal damage. Teaching eye protection (D) is the priority. Resolution timeline (A), heat (B), and diet (C) are secondary.
Which diagnostic test is used to confirm the diagnosis of Amyotrophic Lateral Sclerosis (ALS)?
- A. Electromyogram (EMG).
- B. Muscle biopsy.
- C. Serum creatine kinase (CK).
- D. Pulmonary function test.
Correct Answer: A
Rationale: EMG (A) detects abnormal muscle electrical activity characteristic of ALS, confirming the diagnosis. Muscle biopsy (B) is less specific, CK (C) may be elevated but isn’t diagnostic, and pulmonary tests (D) assess complications, not diagnosis.
The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
- A. Crackles in the upper lung fields and jugular vein distention.
- B. Muscle weakness in the upper extremities and ptosis.
- C. Exaggerated arm swinging and scanning speech.
- D. Masklike facies and a shuffling gait.
Correct Answer: D
Rationale: Masklike facies and shuffling gait (D) are hallmark signs of Parkinson’s due to bradykinesia and rigidity. Crackles and JVD (A) suggest heart failure, weakness and ptosis (B) indicate myasthenia gravis, and exaggerated arm swinging (C) is opposite to Parkinson’s.