Nokea
Which measure for preventing impaired skin integrity is appropriate to add to the care plan at this time?
- A. Use an air-fluidized (Clinitron) bed.
- B. Change the client's position every 2 hours.
- C. Rub any reddened areas every 2 hours.
- D. Provide daily treatment in a hyperbaric oxygen chamber.
Correct Answer: B
Rationale: Changing position every 2 hours prevents pressure ulcers in clients with MS who have weakness and numbness.
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The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.
The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach?
- A. There will be a large turban dressing around the skull after surgery.
- B. The client will not be able to eat for four (4) or five (5) days postop.
- C. The client should not blow the nose for two (2) weeks after surgery.
- D. The client will have to lie flat for 24 hours following the surgery.
Correct Answer: C
Rationale: Blowing the nose (C) risks disrupting the surgical site and causing CSF leaks after transsphenoidal surgery. Turban dressings (A) are not used, eating resumes sooner (B), and flat positioning (D) is not required.
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
- A. The client will regain as much neurological function as possible.
- B. The client will have no short-term memory loss.
- C. The client will have improved renal function.
- D. The client will apply hydrocortisone cream daily.
Correct Answer: A
Rationale: The goal for encephalitis is to maximize neurological recovery (A), as inflammation may cause deficits. No memory loss (B) is unrealistic, renal function (C) is unrelated, and hydrocortisone cream (D) is not indicated.
Which rationale explains the transmission of the West Nile virus?
- A. Transmission occurs through exchange of body fluids when sneezing and coughing.
- B. Transmission occurs only through mosquito bites and not between humans.
- C. Transmission can occur from human to human in blood products and breast milk.
- D. Transmission occurs with direct contact from the maculopapular rash drainage.
Correct Answer: B
Rationale: West Nile virus is primarily transmitted via mosquito bites (B), not human-to-human contact, body fluids (A), blood/breast milk (C), or rash drainage (D).