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Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?
- A. A blood glucose level of 480 mg/dL.
- B. A right-sided carotid bruit.
- C. A blood pressure (BP) of 220/120 mm Hg.
- D. The presence of bronchogenic carcinoma.
Correct Answer: C
Rationale: Severe hypertension (BP 220/120 mm Hg, C) is a major risk factor for hemorrhagic stroke due to vessel rupture. High blood glucose (A) is more linked to ischemic stroke, a carotid bruit (B) indicates atherosclerosis, and bronchogenic carcinoma (D) is unrelated.
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When is the best time to clip the client's hair?
- A. The night before surgery
- B. In the morning, after a shower
- C. Right before entering the operating room
- D. Before surgery, in the operating room area
Correct Answer: D
Rationale: Clipping hair in the operating room area minimizes infection risk by reducing the time the scalp is exposed.
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.
The nurse arrives at the scene of a motor-vehicle accident and the car is leaking gasoline. The client is in the driver's seat of the car complaining of not being able to move the legs. Which actions should the nurse implement? List in order of priority.
- A. Move the client safely out of the car.
- B. Assess the client for other injuries.
- C. Stabilize the client's neck.
- D. Notify the emergency medical system.
- E. Place the client in a functional anatomical position.
Correct Answer: C,B,A,D,E
Rationale: Stabilize the client’s neck (C): Prevents spinal injury. 2. Assess for other injuries (B): Identifies life-threatening issues. 3. Move the client safely (A): Removes from gasoline danger. 4. Notify EMS (D): Ensures professional help. 5. Place in anatomical position (E): Least urgent.
The client with a history of migraine headaches comes to the clinic and reports that a migraine is coming because the client is experiencing bright spots before the eyes. Which phase of migraine headaches is the client experiencing?
- A. Prodrome phase.
- B. Aura phase.
- C. Headache phase.
- D. Recovery phase.
Correct Answer: B
Rationale: Bright spots are visual auras (B), a sensory warning preceding migraines. Prodrome (A) involves mood changes, headache (C) is pain, and recovery (D) follows pain.
When preparing the client for an EEG, which nursing action is most appropriate?
- A. Administer a sedative 1 hour before the test.
- B. Withhold food and water after midnight on the day of the test.
- C. Assist with shampooing the client's hair.
- D. Take the client's blood pressure while lying and sitting.
Correct Answer: C
Rationale: Shampooing the client's hair ensures a clean scalp, improving electrode contact for an accurate EEG.