Nokea
Which assessment finding is especially important to monitor when caring for a client with myasthenia gravis who is in crisis?
- A. Breathing
- B. Temperature
- C. Blood pressure
- D. Mental status
Correct Answer: A
Rationale: Respiratory muscle weakness in myasthenic crisis can lead to respiratory failure, making breathing the most critical assessment.
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The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client?
- A. Hospice nurse.
- B. Speech therapist.
- C. Physical therapist.
- D. Occupational therapist.
Correct Answer: B
Rationale: Glossopharyngeal nerve paralysis affects swallowing and speech. A speech therapist (B) is most appropriate to address these deficits. Hospice (A) is for end-of-life care, physical therapy (C) focuses on mobility, and occupational therapy (D) addresses daily activities.
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem 'altered cerebral tissue perfusion'?
- A. The client will be able to complete activities of daily living.
- B. The client will be protected from injury if seizure activity occurs.
- C. The client will be afebrile for 48 hours prior to discharge.
- D. The client will have elastic tissue turgor with ready recoil.
Correct Answer: B
Rationale: Altered cerebral perfusion in meningitis may lead to seizures. Protecting from injury during seizures (B) addresses this risk. ADLs (A), fever (C), and tissue turgor (D) are unrelated to perfusion.
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
- A. Examine pupil reactions to light.
- B. Assess level of consciousness.
- C. Observe for seizure activity.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
- A. A subcutaneous anticoagulant.
- B. An intravenous osmotic diuretic.
- C. An oral anticonvulsant.
- D. An oral proton pump inhibitor.
Correct Answer: A
Rationale: Subcutaneous anticoagulants (A) increase bleeding risk in head injury patients, where intracranial hemorrhage is a concern, and should be questioned. Osmotic diuretics (B) reduce ICP, anticonvulsants (C) prevent seizures, and proton pump inhibitors (D) protect against stress ulcers.
The nurse writes the problem 'high risk for impaired skin integrity' for the client with an L5-6 spinal cord injury. Which intervention should the nurse include in the plan of care?
- A. Perform active range-of-motion exercise.
- B. Massage the legs and trochanters every shift.
- C. Arrange for a Roho cushion in the wheelchair.
- D. Apply petroleum-based lotion to the extremities.
Correct Answer: C
Rationale: A Roho cushion (C) reduces pressure ulcers in SCI patients. Active ROM (A) is not possible, massage (B) risks skin breakdown, and petroleum lotion (D) is not specific.