Nokea
Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply.
- A. Turn the client every two (2) hours.
- B. Encourage the client to increase fluids.
- C. Keep the client in the supine position.
- D. Assess for deep vein thrombosis (DVT).
- E. Assess for any alterations in elimination.
Correct Answer: A,D,E
Rationale: Turning every 2 hours (A) prevents pressure ulcers, assessing DVT (D) addresses immobility risks, and monitoring elimination (E) ensures bowel/bladder function. Increased fluids (B) depend on status, and supine positioning (C) may increase ICP.
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The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
- A. Observe the client swallowing for possible aspiration.
- B. Position the client in a semi-Fowler's position when sleeping.
- C. Place a suction setup at the client's bedside during meals.
- D. Refer the client to an occupational therapist for evaluation.
Correct Answer: D
Rationale: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A, C) are related to dysphagia, not agnosia, and semi-Fowler’s position (B) is not specific to agnosia management.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
The nurse writes the nursing diagnosis 'altered body temperature related to damaged temperature regulating mechanism' for a client with a head injury. Which would be the most appropriate goal?
- A. Administer acetaminophen (Tylenol) for elevated temperature.
- B. The client's temperature will remain less than 100°F.
- C. Maintain the hypothermia blanket at 99°F for 24 hours.
- D. The basal metabolic temperature will fluctuate no more than two (2) degrees.
Correct Answer: B
Rationale: The goal for altered body temperature is to maintain a normal range, such as less than 100°F (B). Administering medication (A) is an intervention, hypothermia blanket (C) is specific, and basal fluctuation (D) is vague.
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client's significant other?
- A. Awaken the client every two (2) hours.
- B. Monitor for increased intracranial pressure (ICP).
- C. Observe frequently for hypervigilance.
- D. Offer the client food every three (3) to four (4) hours.
Correct Answer: A
Rationale: For a mild concussion, monitoring for worsening neurological status is key. Awakening every 2 hours (A) allows assessment for altered consciousness. Monitoring ICP (B) is complex and not feasible at home, hypervigilance (C) is not typical, and frequent feeding (D) is unnecessary.
The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply.
- A. Hemoglobin 9.5 g/dL and hematocrit is 31.8%
- B. Taking baclofen 15 mg 3 times per day
- C. Working 4 to 8 hours per week in the family business
- D. Stopped taking amitriptyline 8 weeks earlier
- E. Presence of a cardiac murmur at the tricuspid valve.
- F. Bilateral leg weakness noted when walking in room
Correct Answer: A,B,D,E,F
Rationale: The lower-than-normal Hgb and Hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen (Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. Working 4 to 8 hours per week is a limited number of hours and should not contribute to the client’s fatigue. The client has stopped amitriptyline (Elavil), an antidepressant, and may be clinically depressed. Fatigue is a major symptom of depression. A tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissues. The increased energy expenditure with ambulation can increase fatigue.