Nokea
When preparing the client for the upcoming positron emission tomography (PET) scan, the nurse instructs the client to avoid which substances the day before the test? Select all that apply.
- A. Caffeine
- B. Shampoo
- C. Diuretics
- D. Shellfish
- E. Alcohol
- F. Tobacco
Correct Answer: A,E,F
Rationale: Caffeine, alcohol, and tobacco can affect cerebral metabolism and blood flow, potentially altering PET scan results.
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The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?
- A. Do you have trouble hearing?'
- B. Are you allergic to any type of dairy products?'
- C. Have you eaten anything in the last eight (8) hours?'
- D. Are you uncomfortable in closed spaces?'
Correct Answer: D
Rationale: MRI scans require lying still in a confined space, so assessing for claustrophobia (D) is critical to ensure patient safety and comfort. Hearing issues (A), dairy allergies (B), and recent eating (C) are not relevant to MRI preparation.
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.
Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
- A. The client has flaccid paralysis.
- B. The client has purposeful movement.
- C. The client has decerebrate posturing with painful stimuli.
- D. The client does not move the extremities.
Correct Answer: B
Rationale: Purposeful movement (B) indicates improved brain function compared to decorticate posturing. Flaccid paralysis (A) or decerebrate posturing (C) suggest worsening, and no movement (D) is not an improvement.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document?
- A. Hemiparesis of the client's left arm and apraxia.
- B. Paralysis of the right side of the body and ataxia.
- C. Homonymous hemianopsia and diplopia.
- D. Impulsive behavior and hostility toward family.
Correct Answer: B
Rationale: A left-sided CVA affects the right side of the body due to the brain's contralateral control. Paralysis or hemiparesis of the right side is a common manifestation, and ataxia (impaired coordination) may also occur. Hemiparesis of the left arm would indicate a right-sided CVA, visual deficits like homonymous hemianopsia are possible but less specific to motor loss, and behavioral changes are not directly related to motor deficits.
Which finding is considered to be one of the warning signs of developing Alzheimer's disease?
- A. Difficulty performing familiar tasks.
- B. Problems with orientation to date, time, and place.
- C. Having problems focusing on a task.
- D. Atherosclerotic changes in the vessels.
Correct Answer: A
Rationale: Difficulty performing familiar tasks (A) is an early Alzheimer’s sign due to cognitive decline. Orientation issues (B) occur later, focus problems (C) are nonspecific, and atherosclerosis (D) is unrelated.