Nokea
When is the best time to clip the client's hair?
- A. The night before surgery
- B. In the morning, after a shower
- C. Right before entering the operating room
- D. Before surgery, in the operating room area
Correct Answer: D
Rationale: Clipping hair in the operating room area minimizes infection risk by reducing the time the scalp is exposed.
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The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
- A. Examine pupil reactions to light.
- B. Assess level of consciousness.
- C. Observe for seizure activity.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.
Which assessment finding indicates a potential spinal shock in a client with a spinal cord injury?
- A. Flaccid paralysis below the injury
- B. Spastic movements in lower limbs
- C. Intact sensation below the injury
- D. Elevated blood pressure
Correct Answer: A
Rationale: Spinal shock is characterized by flaccid paralysis and loss of reflexes below the injury level immediately after a spinal cord injury.
The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report?
- A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
- B. The client with an L4 SCI who is crying and very upset about being discharged home.
- C. The client with an L2 SCI who is complaining of a headache and feeling very hot.
- D. The client with a T4 SCI who is unable to move the lower extremities.
Correct Answer: A
Rationale: Dyspnea and crackles in a C6 SCI patient (A) suggest respiratory compromise, a life-threatening condition requiring immediate assessment. Emotional distress (B), headache (C), or expected paralysis (D) are less urgent.
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.