Nokea
When the nurse describes the myelogram procedure to the client, which statement is most accurate?
- A. Part of the test involves a lumbar puncture.'
- B. You will be asked to change positions frequently.'
- C. Dye is instilled into a vein in your arm.'
- D. Light anesthesia is administered during the test.'
Correct Answer: A
Rationale: A myelogram involves a lumbar puncture to inject contrast dye into the spinal canal for imaging.
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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 client is diagnosed with ALS. Which client problem would be most appropriate for this client?
- A. Disuse syndrome.
- B. Altered body image.
- C. Fluid and electrolyte imbalance.
- D. Alteration in pain.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness, leading to disuse syndrome (A) from immobility. Body image (B) is secondary, fluid/electrolyte issues (C) are not primary, and pain (D) is less common.
Which intervention is most appropriate for a client with Bell's palsy experiencing eye dryness?
- A. Apply warm compresses to the affected eye.
- B. Administer oral antihistamines.
- C. Use artificial tears as prescribed.
- D. Cover the unaffected eye with a patch.
Correct Answer: C
Rationale: Artificial tears prevent corneal damage from eye dryness in Bell's palsy due to incomplete eye closure.
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.
The client asks the nurse, 'What causes Creutzfeldt-Jakob disease?' Which statement would be the nurse's best response?
- A. The person must have been exposed to an infected prion.'
- B. It is mad cow disease, and eating contaminated meat is the cause.'
- C. This disease is caused by a virus that is in stagnant water.'
- D. A fungal spore from the lungs infects the brain tissue.'
Correct Answer: A
Rationale: Creutzfeldt-Jakob disease is caused by prions (A), infectious proteins. Mad cow (B) is a variant but not the sole cause, and viral (C) or fungal (D) causes are incorrect.