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Which finding is considered to be one of the warning signs of developing Alzheimer's disease?
- A. Difficulty performing familiar tasks.
- B. Problems with orientation to date, time, and place.
- C. Having problems focusing on a task.
- D. Atherosclerotic changes in the vessels.
Correct Answer: A
Rationale: Difficulty performing familiar tasks (A) is an early Alzheimer’s sign due to cognitive decline. Orientation issues (B) occur later, focus problems (C) are nonspecific, and atherosclerosis (D) is unrelated.
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The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
- A. The client will maintain body weight within two (2) pounds.
- B. The client will execute an advance directive.
- C. The client will be able to perform three (3) ADLs with assistance.
- D. The client will verbalize feeling of loss by the end of the shift.
Correct Answer: C
Rationale: A realistic goal for self-care deficit is performing ADLs with assistance (C), addressing functional limitations due to the tumor. Weight maintenance (A), advance directives (B), and verbalizing loss (D) are not directly related to self-care.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- A. Assess the client's level of consciousness.
- B. Organize onlookers to remove the client from the lake.
- C. Perform a head-to-toe assessment to determine injuries.
- D. Stabilize the client's cervical spine.
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (A), organizing removal (B), or performing a full assessment (C) follows.
Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
- A. Poor skin turgor
- B. Decerebrate posturing
- C. Deep tendon reflexes
- D. Absent corneal reflex
- E. Dilated nonreactive pupils
- F. Dry mucous membranes
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.
The client is to receive a 100-mL intravenous antibiotic over 30 minutes via an intravenous pump. At what rate should the nurse set the IV pump?
Correct Answer: 200 mL/hr
Rationale: To infuse 100 mL over 30 minutes, calculate the hourly rate: (100 mL / 30 min) × 60 min/hr = 200 mL/hr. The pump should be set to 200 mL/hr.
Which postoperative complication should the nurse monitor most closely after a craniotomy?
- A. Hypotension
- B. Cerebrospinal fluid leak
- C. Mild fever
- D. Constipation
Correct Answer: B
Rationale: A cerebrospinal fluid leak is a critical complication post-craniotomy, increasing infection risk and requiring immediate intervention.