Nokea
Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
- A. Complete neurovascular examinations every eight (8) hours.
- B. Maintain accurate intake and output at the end of each shift.
- C. Assess the client’s symptoms to determine if there is improvement.
- D. Administer intravenous fluids while assessing for overload.
Correct Answer: D
Rationale: IV fluids (D) support hydration in West Nile virus while monitoring for overload prevents complications. Neurovascular exams (A) are less relevant, intake/output (B) is routine, and symptom assessment (C) is nursing-driven.
You may also like to solve these questions
Before discharge, the nurse instructs the client about administering subcutaneous injections and correctly explains the client should rotate injections between which two areas?
- A. Thighs and hips
- B. Forearms and hips
- C. Thighs and abdomen
- D. Abdomen and buttocks
Correct Answer: C
Rationale: Rotating injections between the thighs and abdomen minimizes tissue damage and ensures consistent absorption.
The nurse is caring for the client who had a stroke affecting the right hemisphere of the brain. The nurse should assess for which problem initially?
- A. Right hemiparesis
- B. Expressive aphasia
- C. Poor impulse control
- D. Tetraplegia
Correct Answer: C
Rationale: A stroke affecting the right hemisphere may produce left, not right hemiparesis. Motor fibers in the brain cross over in the medulla before entering the spinal column. This client may or may not have aphasia because the center for language is located on the left side of the brain in 75% to 80% of the population; this client had a stroke involving the right hemisphere. Even though the client may have expressive aphasia, it is more important to assess for poor impulse control due to the risk for injury. The client with a stroke affecting the right side of the brain often exhibits impulsive behavior and is unaware of the neurological deficits. Poor impulse control increases the client’s risk for injury. Tetraplegia (quadriplegia) is associated with an SCI; tetraplegia usually does not occur from a stroke.
If the client had been unresponsive except to painful stimuli, which new assessment finding indicates that the client is improving?
- A. Pupils are fixed when stimulated with light.
- B. Pupils are unequal when stimulated with light.
- C. Client's Glasgow Coma Scale score is 12.
- D. Stroking the cheek with a swab causes swallowing.
Correct Answer: C
Rationale: A Glasgow Coma Scale score of 12 indicates improved responsiveness compared to being unresponsive except to painful stimuli, suggesting neurological improvement.
Which behavior is a risk factor for developing and spreading bacterial meningitis?
- A. An upper respiratory infection (URI).
- B. Unprotected sexual intercourse.
- C. Chronic alcohol consumption.
- D. Use of tobacco products.
Correct Answer: A
Rationale: URI (A) increases the risk of bacterial meningitis by facilitating bacterial invasion. Sexual intercourse (B), alcohol (C), and tobacco (D) are not direct risk factors.
The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
- A. The client will maintain body weight within two (2) pounds.
- B. The client will execute an advance directive.
- C. The client will be able to perform three (3) ADLs with assistance.
- D. The client will verbalize feeling of loss by the end of the shift.
Correct Answer: C
Rationale: A realistic goal for self-care deficit is performing ADLs with assistance (C), addressing functional limitations due to the tumor. Weight maintenance (A), advance directives (B), and verbalizing loss (D) are not directly related to self-care.