Nokea
Which client response depicts normal function of cranial nerve XI?
- A. A client wrinkling the forehead
- B. A client puffing out the cheeks
- C. A client sticking out the tongue
- D. A client shrugging the shoulders
Correct Answer: D
Rationale: Cranial nerve XI (spinal accessory) innervates the trapezius and sternocleidomastoid muscles, enabling shoulder shrugging.
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The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client’s treatment with mannitol?
- A. Serum osmolarity
- B. White blood cell count
- C. Serum cholesterol
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Mannitol (Osmitrol), an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage. The WBC count is not affected by mannitol. Serum cholesterol is not affected by mannitol. ESR is not affected by mannitol.
While awaiting the diagnostic test results for a client with possible meningitis, which transmission-based precautions are the supplement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: A
Rationale: Meningitis, especially bacterial, is often transmitted via respiratory droplets, necessitating droplet precautions.
A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?
- A. It stimulated a heartbeat when bradycardia occurred during a seizure.
- B. It defibrillated a lethal rhythm that occurred during the client’s seizure.
- C. The client activates the VNS device to stop a seizure from occurring.
- D. The client activates the device at seizure onset to prevent aspiration.
Correct Answer: C
Rationale: A VNS device does not stimulate the heart to beat as a pacemaker. A VNS device does not defibrillate the heart as an implantable cardioverter/defibrillator does. A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure. The device does not have an effect on the airway or secretions.
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?
- A. Discuss how to correctly remove the insertion pins.
- B. Instruct the client to report reddened or irritated skin areas.
- C. Inform the client that the vest liner cannot be changed.
- D. Encourage the client to remain in the recliner as much as possible.
Correct Answer: B
Rationale: Skin integrity under a halo device is critical. Instructing to report reddened or irritated skin (B) prevents pressure ulcers. Removing pins (A) is done by providers, the vest liner can be changed (C), and prolonged recliner use (D) risks immobility complications.
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.