Nokea
When planning care for this client, which equipment is most important for the nurse to keep at the bedside?
- A. A cardiac defibrillator in case of cardiac arrest
- B. A suction machine in case of compromised swallowing
- C. A cooling blanket in case of hyperthermia
- D. An IV infusion pump for fluid administration
Correct Answer: B
Rationale: A suction machine is essential to clear secretions in myasthenia gravis clients with compromised swallowing, preventing aspiration.
You may also like to solve these questions
Which instruction is most applicable after symptoms are relieved?
- A. Carry heavy objects away from your center of gravity.
- B. Lift with your knees bent and your back straight.
- C. Create a base of support by keeping your feet together.
- D. Select a soft, spongy mattress for your bed.
Correct Answer: B
Rationale: Lifting with knees bent and back straight prevents re-injury to the lumbar spine after a herniated disk.
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.
The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving?
- A. The current GSC rating is 3.
- B. The current GSC rating is 9.
- C. The current GSC rating is 10.
- D. The current GSC rating is 12.
Correct Answer: D
Rationale: A GCS of 12 (D) is higher than 10, indicating improved neurological status. Scores of 3 (A) or 9 (B) indicate worsening, and 10 (C) shows no change.
The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?
- A. The client has purposeful movement with painful stimuli.
- B. The client has assumed adduction of the upper extremities.
- C. The client is aimlessly thrashing in the bed.
- D. The client has become flaccid and does not respond to stimuli.
Correct Answer: D
Rationale: Flaccid paralysis and unresponsiveness (D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (A) or thrashing (C) suggest improvement, and adduction (B) is not a standard indicator.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.