Nokea
Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis?
- A. History of a cold or gastrointestinal upset in the last month.
- B. Complaints of double vision and drooping eyelids.
- C. Fatigue, progressive muscle weakness, and twitching.
- D. Loss of sensation below the level of the umbilicus.
Correct Answer: C
Rationale: ALS presents with fatigue, progressive muscle weakness, and fasciculations (twitching, C). Recent illness (A) is nonspecific, double vision/ptosis (B) suggests myasthenia gravis, and sensory loss (D) is not typical of ALS.
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The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan?
- A. Ensure the traction weight hangs freely
- B. Remove the vest from the device at bedtime
- C. Cleanse sites where the pins enter the skull
- D. Screw the pins in the skull daily to tighten.
Correct Answer: C
Rationale: Neither traction nor weights are part of the halo device. The halo external fixation device includes a vest that is worn continuously and should not be removed. The neurosurgeon will discontinue it when the injury has stabilized and sufficient healing has occurred. A halo external fixation device is a static device that consists of a “halo” that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pin sites. The nurse should not tighten the pins. These are secured in the skull to maintain alignment of the cervical vertebrae. If loose, the nurse should contact the HCP for tightening.
The client is prescribed a loading dose of phenytoin of 15 mg/kg IV for seizure activity, then 100 mg IV tid. The client weighs 198 lb. What dose in mg should the nurse administer for the loading dose of phenytoin?
- A. 1350 mg IV
Correct Answer: 1350
Rationale: 198 lb = 90 kg; (198 ÷ 2.2 = 90 kg; 90 x 15 = 1350) The nurse should administer 1350 mg phenytoin (Dilantin).
The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
- A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78.
- B. The client complains of generalized body aches and pains.
- C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA).
- D. The client becomes lethargic and is difficult to arouse using verbal stimuli.
Correct Answer: D
Rationale: Lethargy and difficulty arousing (D) indicate neurological deterioration, requiring immediate intervention. Mild fever (A), body aches (B), and positive ELISA (C) are expected.
The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding?
- A. A residual of 125 mL.
- B. The abdomen is soft.
- C. Three episodes of diarrhea.
- D. The potassium level is 3.4 mEq/L.
Correct Answer: A
Rationale: A gastric residual of 125 mL (A) indicates delayed gastric emptying, requiring the feeding to be held to prevent aspiration. Soft abdomen (B) is normal, diarrhea (C) requires monitoring but not holding, and low potassium (D) is unrelated.
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
- A. Obtain an informed consent from the client or significant other.
- B. Have the client empty the bladder prior to the procedure.
- C. Place the client in a side-lying position with the back arched.
- D. Instruct the client to breathe rapidly and deeply during the procedure.
- E. Explain to the client what to expect during the procedure.
Correct Answer: A,B,C,E
Rationale: Informed consent (A) is required, emptying the bladder (B) ensures comfort, side-lying with back arched (C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (D) is not advised.