Nokea
When planning a bowel retraining program for a client with a spinal cord injury, which nursing intervention is most appropriate?
- A. Administering a stool softener twice per week
- B. Encouraging the client to consume a high-fiber diet
- C. Having the client drink two glasses of water every morning
- D. Teaching the client to self-administer daily enemas
Correct Answer: B
Rationale: A high-fiber diet promotes regular bowel movements, which is essential for bowel retraining in spinal cord injury clients.
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Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
- A. Poor skin turgor
- B. Decerebrate posturing
- C. Deep tendon reflexes
- D. Absent corneal reflex
- E. Dilated nonreactive pupils
- F. Dry mucous membranes
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.
Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
Which assessment finding is especially important to monitor when caring for a client with myasthenia gravis who is in crisis?
- A. Breathing
- B. Temperature
- C. Blood pressure
- D. Mental status
Correct Answer: A
Rationale: Respiratory muscle weakness in myasthenic crisis can lead to respiratory failure, making breathing the most critical assessment.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- A. Assess the client's level of consciousness.
- B. Organize onlookers to remove the client from the lake.
- C. Perform a head-to-toe assessment to determine injuries.
- D. Stabilize the client's cervical spine.
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (A), organizing removal (B), or performing a full assessment (C) follows.
The nurse is assessing the client following a closed head injury. When applying nailbed pressure, the client’s body suddenly stiffens, the eyes roll upward, and there is an increase in salivation and loss of swallowing reflex. Which observation should the nurse document?
- A. Decerebrate posturing observed
- B. Decorticate posturing observed
- C. Positive Kernig’s sign observed
- D. Seizure activity observed
Correct Answer: D
Rationale: Decerebrate posture involves rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. Decorticate posture involves rigidity, flexion of the arms toward the body with the wrists and fingers clenched and held on the chest, and the legs extended. A positive Kernig’s sign is flexing the leg at the hip and then raising the leg into extension. Severe head and neck pain occurs. Body stiffening, eyes rolled upward, increase in salivation, and a loss of swallowing reflex are signs consistent with the tonic phase of a tonic-clonic seizure. This phase is followed by the clonic phase with violent muscle contractions.