Nokea
Which discharge instruction is most appropriate following the positron emission tomography scan?
- A. Take a mild sedative tonight.
- B. Increase your fluid intake.
- C. Avoid excessive sitting.
- D. Report signs of a fever.
Correct Answer: B
Rationale: Increasing fluid intake helps flush the radioactive tracer used in the PET scan from the body.
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The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
The student nurse asks the nurse, 'Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?' The nurse would base the response on which scientific rationale?
- A. This is part of the routine neurological examination.
- B. This is done to determine if the client has diplopia.
- C. This assesses the amount of brain damage.
- D. This is done to indicate if there is a rebound effect on the brain.
Correct Answer: B
Rationale: Frontal head injuries may affect the occipital lobe or optic pathways, causing diplopia (double vision, B). Routine exams (A) are broader, brain damage (C) is not specific, and rebound effect (D) is not a term used here.
Which information should be shared with the client diagnosed with stage I Alzheimer's disease who is prescribed donepezil (Aricept), a cholinesterase inhibitor?
- A. The client must continue taking this medication forever to maintain function.
- B. The drug may delay the progression of the disease, but it does not cure it.
- C. A serum drug level must be obtained monthly to evaluate for toxicity.
- D. If the client develops any muscle aches, the HCP should be notified.
Correct Answer: B
Rationale: Donepezil delays Alzheimer’s progression but does not cure it (B). Lifelong use (A) is not mandatory, serum levels (C) are not routine, and muscle aches (D) are not a primary concern.
Which intervention is most appropriate for a client with a cerebral aneurysm at risk for rupture?
- A. Encourage deep coughing exercises.
- B. Maintain a quiet, dimly lit environment.
- C. Administer high-dose corticosteroids.
- D. Promote early ambulation.
Correct Answer: B
Rationale: A quiet, dimly lit environment reduces stimuli that could increase intracranial pressure and risk aneurysm rupture.
Which assessment finding in a client post-diskectomy indicates a potential complication?
- A. Mild incisional pain
- B. Numbness in the toes
- C. Clear urine output
- D. Stable vital signs
Correct Answer: B
Rationale: Numbness in the toes may indicate nerve compression or damage, a potential complication requiring further evaluation.