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Which intervention is most appropriate for a client with a cerebral aneurysm at risk for rupture?
- A. Encourage deep coughing exercises.
- B. Maintain a quiet, dimly lit environment.
- C. Administer high-dose corticosteroids.
- D. Promote early ambulation.
Correct Answer: B
Rationale: A quiet, dimly lit environment reduces stimuli that could increase intracranial pressure and risk aneurysm rupture.
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The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
- A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78.
- B. The client complains of generalized body aches and pains.
- C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA).
- D. The client becomes lethargic and is difficult to arouse using verbal stimuli.
Correct Answer: D
Rationale: Lethargy and difficulty arousing (D) indicate neurological deterioration, requiring immediate intervention. Mild fever (A), body aches (B), and positive ELISA (C) are expected.
The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering?
- A. Thiamine (vitamin B6) and librium, a benzodiazepine.
- B. Dilantin, an anticonvulsant, and Feosol, an iron preparation.
- C. Methadone, a synthetic narcotic, and Depakote, a mood stabilizer.
- D. Mannitol, an osmotic diuretic, and Ritalin, a stimulant.
Correct Answer: A
Rationale: Delirium tremens requires thiamine (vitamin B1, not B6) to prevent Wernicke’s encephalopathy and benzodiazepines like Librium (A) to manage withdrawal symptoms. Other options are unrelated to delirium tremens management.
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
- A. Obtain an informed consent from the client or significant other.
- B. Have the client empty the bladder prior to the procedure.
- C. Place the client in a side-lying position with the back arched.
- D. Instruct the client to breathe rapidly and deeply during the procedure.
- E. Explain to the client what to expect during the procedure.
Correct Answer: A,B,C,E
Rationale: Informed consent (A) is required, emptying the bladder (B) ensures comfort, side-lying with back arched (C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (D) is not advised.
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client’s spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?
- A. “Plasmapheresis removes excess fluid from the bloodstream.”
- B. “Plasmapheresis will increase the protein levels in the blood.”
- C. “Plasmapheresis removes circulating antibodies from the blood.”
- D. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”
Correct Answer: C
Rationale: Aquapheresis or dialysis, not plasmapheresis, will remove excess fluid from the blood. Plasmapheresis does not increase protein levels in the blood. Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client. Plasmapheresis does not involve infusing lipoproteins.
The student nurse asks the nurse, 'Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?' The nurse would base the response on which scientific rationale?
- A. This is part of the routine neurological examination.
- B. This is done to determine if the client has diplopia.
- C. This assesses the amount of brain damage.
- D. This is done to indicate if there is a rebound effect on the brain.
Correct Answer: B
Rationale: Frontal head injuries may affect the occipital lobe or optic pathways, causing diplopia (double vision, B). Routine exams (A) are broader, brain damage (C) is not specific, and rebound effect (D) is not a term used here.