Nokea
Which discharge teaching is essential for a client with a spinal cord injury to prevent respiratory complications?
- A. Perform deep breathing exercises daily.
- B. Avoid outdoor activities.
- C. Limit fluid intake to reduce secretions.
- D. Sleep in a prone position.
Correct Answer: A
Rationale: Deep breathing exercises help prevent atelectasis and pneumonia in clients with spinal cord injuries.
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The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, 'Why can’t I control these tremors?' Which is the nurse’s best response?
- A. You can control the tremors when you learn to concentrate and focus on the cause.'
- B. The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.'
- C. You have too much acetylcholine in your brain causing the tremors but they will get better with time.'
- D. You are concerned about the tremors? If you want to talk I would like to hear how you feel.'
Correct Answer: B
Rationale: Parkinson’s tremors result from dopamine deficiency (B), and medications like levodopa help. Concentration (A) doesn’t control tremors, acetylcholine imbalance (C) is partial and not time-resolving, and reflection (D) doesn’t answer the question.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.
What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.
The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first?
- A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a '2' on a 1-to-10 scale.
- B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- C. The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
Correct Answer: B
Rationale: Inability to move toes in a T10 SCI (B) may indicate neurological deterioration or edema, requiring immediate assessment. Mild headache (A), emotional distress (C), and resolving hemiparesis (D) are less urgent.
The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care?
- A. Administer antibiotics.
- B. Obtain a sputum culture.
- C. Monitor the pulse oximeter.
- D. Assess intake and output.
Correct Answer: A
Rationale: Bacterial meningitis requires prompt antibiotic administration (A) as a collaborative intervention with the provider. Sputum culture (B) is not relevant, pulse oximetry (C) is supportive, and intake/output (D) is a nursing action.