Nokea
When the client asks why fluids are being restricted, which explanation by the nurse is best?
- A. Large amounts of fluid may contribute to vomiting.'
- B. The kidneys need to conserve fluid output.'
- C. Fluid restriction reduces the volume in the cranium.'
- D. The prescribed volume is sufficient for relieving thirst.'
Correct Answer: C
Rationale: Fluid restriction reduces intracranial volume, minimizing the risk of increased intracranial pressure post-craniotomy.
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The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
- A. Tell the client to take any routine antiseizure medication prior to the EEG.
- B. Tell the client not to eat anything for eight (8) hours prior to the procedure.
- C. Instruct the client to stay awake for 24 hours prior to the EEG.
- D. Explain to the client that there will be some discomfort during the procedure.
Correct Answer: A
Rationale: Taking routine antiseizure medications (A) ensures therapeutic levels during the EEG, avoiding seizures that could skew results. Fasting (B) is unnecessary, sleep deprivation (C) may be used in specific cases but not routinely, and EEGs are painless (D).
Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
Which intervention is most appropriate for a client with multiple sclerosis experiencing fatigue?
- A. Schedule activities in the late afternoon.
- B. Encourage short, frequent rest periods.
- C. Administer caffeine supplements.
- D. Increase physical therapy sessions.
Correct Answer: B
Rationale: Short, frequent rest periods help manage fatigue in multiple sclerosis by conserving energy.
Which response by the nurse is most appropriate?
- A. Clipping the hair is hospital policy.'
- B. This method is better for you.'
- C. Shaving the head causes microscopic cuts, resulting in risk for infection.'
- D. Surgery could be postponed if bleeding from the scalp occurs.'
Correct Answer: C
Rationale: Clipping avoids microscopic cuts from shaving, reducing infection risk, which is critical for craniotomy.
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
- A. A 55-year-old African American male.
- B. An 84-year-old Japanese female.
- C. A 67-year-old Caucasian male.
- D. A 39-year-old pregnant female.
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.