Nokea
Which finding in a brain-dead client confirms the diagnosis?
- A. Presence of gag reflex
- B. Apnea during an apnea test
- C. Reactive pupils
- D. Spontaneous limb movement
Correct Answer: B
Rationale: Apnea during an apnea test (no spontaneous breathing) is a key criterion for confirming brain death.
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The home health nurse evaluates the foot care of the dark-skinned African client who has peripheral neuropathy. Which client actions in providing foot care are appropriate? Select all that apply.
- A. Uses a mirror and visually inspects the feet on a daily basis
- B. Lotions the feet and legs daily, avoiding between the toes
- C. Goes barefoot when indoors to help dry and air out the feet
- D. Wears warm socks and boots when outside in cold weather
- E. Trims toenails weekly so they have a rounded contour
- F. Inspects the feet for redness and other signs of inflammation
Correct Answer: A,B,D
Rationale: Using a mirror allows for visual inspection of the bottom of the feet and between the toes for areas of skin breakdown. Keeping the skin adequately lubricated with lotion prevents drying and cracking. Lotion should not be applied between the toes because it increases moisture and the risk for infection. Clients should avoid going barefoot because this increases the risk for foot injury. Wearing appropriate clothing protects the skin from injury because sensation is diminished with peripheral neuropathy. Toenails should be trimmed straight across to avoid damaging the tissue, which is slow to heal in the presence of peripheral neuropathy. In a dark-skinned client, areas of inflammation may appear purplish-blue or violet rather than appearing reddened (erythematous).
When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?
- A. 1/4'' (0.6 cm)
- B. 1/2'' (1.3 cm)
- C. 1'' (2.5 cm)
- D. 2'' (5 cm)
Correct Answer: C
Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
- A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- B. Discuss the precipitating factors that caused the symptoms.
- C. Schedule for a STAT computed tomography (CT) scan of the head.
- D. Notify the speech pathologist for an emergency consult.
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?
Correct Answer: 4 gtts/min
Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
- A. This must be very hard for you. You’re feeling worthless?'
- B. You shouldn’t feel worthless—you are still alive.'
- C. Why do you feel worthless? You still have the use of your arms.'
- D. If you attended a work rehab program you wouldn’t feel worthless.'
Correct Answer: A
Rationale: Reflecting the client’s feelings (A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (B), challenge the client inappropriately (C), or assume solutions (D).