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Which clinical manifestation will the nurse most likely observe first?
- A. Excessive jerking of the entire body
- B. Sleepiness and disorientation
- C. Loss of consciousness
- D. Absence of deep tendon reflexes
Correct Answer: B
Rationale: In the postictal phase, sleepiness and disorientation are typically observed first as the brain recovers from the seizure.
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The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
The nurse is caring for several clients on a medical unit. Which client should the nurse assess first?
- A. The client with ALS who is refusing to turn every two (2) hours.
- B. The client with abdominal pain who is complaining of nausea.
- C. The client with pneumonia who has a pulse oximeter reading of 90%.
- D. The client who is complaining about not receiving any pain medication.
Correct Answer: C
Rationale: A pulse oximetry of 90% (C) indicates hypoxemia, requiring immediate assessment to prevent respiratory compromise. Refusing turning (A), nausea (B), and pain complaints (D) are less urgent.
The client diagnosed with septic meningitis is admitted to the medical floor at noon. Which health-care provider’s order would have the highest priority?
- A. Administer an intravenous antibiotic.
- B. Obtain the client’s lunch tray.
- C. Provide a quiet, calm, and dark room.
- D. Weigh the client in hospital attire.
Correct Answer: A
Rationale: Prompt IV antibiotic administration (A) is critical in septic meningitis to combat infection and prevent complications. Lunch (B), environment (C), and weight (D) are secondary.
The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.