Nokea
Which client should the nurse assess first after receiving the shift report?
- A. The client diagnosed with a stroke who has right-sided paralysis.
- B. The client diagnosed with meningitis who complains of photosensitivity.
- C. The client with a brain tumor who has projectile vomiting.
- D. The client with epilepsy who complains of tender gums.
Correct Answer: C
Rationale: Projectile vomiting (C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (A), photosensitivity (B), and tender gums (D) are less urgent.
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Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
Which environmental modifications should the nurse implement? Select all that apply.
- A. Keep the room dark and quiet.
- B. Lower the bed to the lowest position.
- C. Keep the side rails up and padded.
- D. Provide soft, soothing music.
- E. Ensure a warm, well-lit room.
- F. Make sure suction equipment is available.
Correct Answer: B,C,F
Rationale: Lowering the bed, padding side rails, and ensuring suction equipment availability reduce injury risk and manage complications during a seizure.
The nurse assessed the client newly diagnosed with MG. Which finding should the nurse recognize as being unrelated to the diagnosis?
- A. Drooping eyelids
- B. Slurred speech
- C. Weak lower extremities
- D. Circumoral tingling
Correct Answer: D
Rationale: Ptosis (drooping eyelids) is a sign of muscle weakness often seen with MG. If the muscles involved with speech are weak in the client with MG, the client may exhibit slurred speech. Clients with MG may demonstrate weakness in the lower extremities. Numbness around the mouth is not associated with muscle weakness but could be indicative of a calcium deficiency or some other problem.
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 client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.