Nokea
Which finding in a client post-stroke indicates a need for immediate intervention?
- A. Blood pressure of 180/100 mmHg
- B. Mild weakness in the right arm
- C. Difficulty finding words
- D. Fatigue after physical therapy
Correct Answer: A
Rationale: Severe hypertension post-stroke increases the risk of hemorrhage or further brain injury, requiring immediate intervention.
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When is the best time to clip the client's hair?
- A. The night before surgery
- B. In the morning, after a shower
- C. Right before entering the operating room
- D. Before surgery, in the operating room area
Correct Answer: D
Rationale: Clipping hair in the operating room area minimizes infection risk by reducing the time the scalp is exposed.
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem 'altered cerebral tissue perfusion'?
- A. The client will be able to complete activities of daily living.
- B. The client will be protected from injury if seizure activity occurs.
- C. The client will be afebrile for 48 hours prior to discharge.
- D. The client will have elastic tissue turgor with ready recoil.
Correct Answer: B
Rationale: Altered cerebral perfusion in meningitis may lead to seizures. Protecting from injury during seizures (B) addresses this risk. ADLs (A), fever (C), and tissue turgor (D) are unrelated to perfusion.
Before requesting the clear liquids prescribed by the physician, which assessment information is essential for the nurse to know?
- A. The client's ability to raise the head
- B. The client's preferences of clear liquids
- C. Whether the client's bowel sounds have returned
- D. The client's ability to swallow effectively
Correct Answer: D
Rationale: Assessing the ability to swallow ensures safety when initiating oral intake post-craniotomy.
Which assessment finding is especially important to monitor when caring for a client with myasthenia gravis who is in crisis?
- A. Breathing
- B. Temperature
- C. Blood pressure
- D. Mental status
Correct Answer: A
Rationale: Respiratory muscle weakness in myasthenic crisis can lead to respiratory failure, making breathing the most critical assessment.
Which intervention is priority for a client with AIDS dementia complex experiencing agitation?
- A. Administer a sedative as prescribed.
- B. Provide a quiet, low-stimulus environment.
- C. Restrain the client to prevent injury.
- D. Encourage group activities to distract the client.
Correct Answer: B
Rationale: A quiet, low-stimulus environment reduces agitation in clients with AIDS dementia complex by minimizing sensory overload.