Nokea
Which assessment finding post-craniotomy requires immediate reporting to the physician?
- A. Clear drainage from the incision
- B. Pain controlled with analgesics
- C. Stable vital signs
- D. Mild swelling at the incision site
Correct Answer: A
Rationale: Clear drainage may indicate a cerebrospinal fluid leak, a serious complication requiring immediate intervention.
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The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
- A. Position the client to prevent shoulder adduction.
- B. Turn and reposition the client every shift.
- C. Encourage the client to move the affected side.
- D. Perform quadriceps exercises three (3) times a day.
- E. Instruct the client to hold the fingers in a fist.
Correct Answer: A,C,D
Rationale: For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (C) promotes neuroplasticity and recovery. Quadriceps exercises (D) strengthen the affected leg. Turning every shift (B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.
Which client statement indicates a need for further teaching about meningitis precautions?
- A. I'll wear a mask when visitors come.'
- B. My family should wash their hands frequently.'
- C. I can share my water bottle with my spouse.'
- D. I'll stay in my room to avoid spreading germs.'
Correct Answer: C
Rationale: Sharing a water bottle can transmit meningitis, indicating a misunderstanding of droplet precaution protocols.
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
- A. The client will return to work within six (6) months.
- B. The client is able to focus and stay on task for 10 minutes.
- C. The client will be able to dress self without assistance.
- D. The client will regain bowel and bladder control.
Correct Answer: B
Rationale: Cognitive deficits post-TBI may limit complex tasks. Focusing for 10 minutes (B) is a realistic short-term goal to build cognitive endurance. Returning to work (A) may be unrealistic within 6 months, dressing independently (C) requires motor and cognitive skills, and bowel/bladder control (D) may be affected by physical deficits.
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?
- A. Assess lung sounds.
- B. Assess the six cardinal fields of gaze.
- C. Assess apical pulse.
- D. Assess level of consciousness.
Correct Answer: D
Rationale: Level of consciousness (D) is the priority assessment in meningitis, as it indicates neurological status and potential complications like increased ICP. Lung sounds (A), eye movements (B), and pulse (C) are secondary.
The client who has expressive aphasia is having difficulty communicating with the nurse. Which action by the nurse would be most helpful?
- A. Position the client facing the nurse
- B. Enunciate directions very slowly
- C. Use gestures and body language
- D. Ask the client to point to needed objects
Correct Answer: D
Rationale: Having the client face the nurse will not aid the client in expressing his or her needs. The nurse’s slow enunciation of directions will not aid the client in expressing his or her needs. Using gestures and body language will not aid the client in expressing his or her needs. Asking the client to point to needed objects would be most helpful when the client is having difficulty communicating with the nurse.