Nokea
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.
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Which assessment data would make the nurse suspect that the client with a C7 spinal cord injury is experiencing autonomic dysreflexia?
- A. Abnormal diaphoresis.
- B. A severe throbbing headache.
- C. Sudden loss of motor function.
- D. Spastic skeletal muscle movement.
Correct Answer: B
Rationale: Autonomic dysreflexia in SCI causes severe headache (B) due to hypertensive crisis from a trigger like bladder distention. Diaphoresis (A) is secondary, motor loss (C) is expected, and spasticity (D) is chronic.
The husband of a client who is an alcoholic tells the nurse, 'I don’t know what to do. I don’t know how to deal with my wife’s problem.' Which response would be most appropriate by the nurse?
- A. It must be difficult. Maybe you should think about leaving.'
- B. I think you should attend Alcoholics Anonymous.'
- C. I think that Alanon might be very helpful for you.'
- D. You should not enable your wife’s alcoholism.'
Correct Answer: C
Rationale: Alanon (C) supports families of alcoholics, offering coping strategies. Suggesting leaving (A) is judgmental, AA (B) is for alcoholics, and accusing enabling (D) may alienate.
A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
- A. Administer a stool softener bid.
- B. Encourage the client to cough hourly.
- C. Monitor neurological status every shift.
- D. Maintain the dopamine drip to keep BP at 160/90.
Correct Answer: A
Rationale: Post-craniotomy for subarachnoid hemorrhage, preventing increased intracranial pressure is critical. A stool softener (A) prevents straining, which could raise ICP. Coughing (B) increases ICP, neurological checks (C) should be more frequent (e.g., hourly), and dopamine to maintain high BP (D) risks re-bleeding.
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.
The nurse is administering mannitol IV to decrease the client’s ICP following a craniotomy. Which laboratory test result should the nurse monitor during the client’s treatment with mannitol?
- A. Serum osmolarity
- B. White blood cell count
- C. Serum cholesterol
- D. Erythrocyte sedimentation rate (ESR)
Correct Answer: A
Rationale: Mannitol (Osmitrol), an osmotic diuretic, increases the serum osmolarity and pulls fluid from the tissues, thus decreasing cerebral edema postoperatively. Serum osmolarity levels should be assessed as a parameter to determine proper dosage. The WBC count is not affected by mannitol. Serum cholesterol is not affected by mannitol. ESR is not affected by mannitol.