Nokea
When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.
- A. Avoid twisting or jerking the back.
- B. Wear a soft back brace at all times.
- C. Avoid sitting for long periods during the first week.
- D. Bend from the waist when picking up items from the floor.
- E. Monitor urine output for the first week.
- F. Report lower extremity color changes to the physician.
Correct Answer: A,C,F
Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.
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The nurse stops at the scene of a motor-vehicle accident and provides emergency first aid at the scene. Which law protects the nurse as a first responder?
- A. The First Aid Law.
- B. Ombudsman Act.
- C. Good Samaritan Act.
- D. First Responder Law.
Correct Answer: C
Rationale: The Good Samaritan Act (C) protects nurses providing emergency care from liability. First Aid Law (A) and First Responder Law (D) are not standard, and Ombudsman Act (B) is unrelated.
Which sign or symptom in the client's medical history would most likely indicate a manifestation of the client's disease?
- A. Sudden hearing loss
- B. Sensitivity to light
- C. Drooping eyelids
- D. Protruding tongue
Correct Answer: C
Rationale: Drooping eyelids (ptosis) is a common symptom of myasthenia gravis due to muscle weakness affecting the ocular muscles.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply.
- A. Determine if the client has recently received any immunizations.
- B. Ask the client if he or she has had a cold in the last week.
- C. Check to see if the client has active herpes simplex 1.
- D. Find out if the client has traveled to the Great Lakes region.
- E. Assess for exposure to soil with fungal spores.
Correct Answer: C
Rationale: Encephalitis is often viral, with herpes simplex virus (HSV-1, C) a common cause, supporting the diagnosis. Recent immunizations (A), colds (B), travel (D), and fungal exposure (E) are less directly linked to encephalitis.
The nurse is preparing the male client for an electroencephalogram (EEG). Which intervention should the nurse implement?
- A. Explain that this procedure is not painful.
- B. Premedicate the client with a benzodiazepine drug.
- C. Instruct the client to shave all facial hair.
- D. Tell the client it will cause him to see 'floaters.'
Correct Answer: A
Rationale: Explaining that the EEG is painless (A) reduces anxiety. Benzodiazepines (B) are not routine, shaving (C) is unnecessary, and floaters (D) are not associated.