Nokea
Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
You may also like to solve these questions
Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease)?
- A. Discuss a percutaneous gastrostomy tube.
- B. Explain how a fistula is accessed.
- C. Provide an advance directive.
- D. Refer to a physical therapist for leg braces.
Correct Answer: C
Rationale: ALS is progressive and terminal. Providing an advance directive (C) ensures the client’s wishes are respected early. Gastrostomy (A) is later, fistulas (B) are unrelated, and leg braces (D) are less urgent.
Before discharge, the nurse instructs the client about administering subcutaneous injections and correctly explains the client should rotate injections between which two areas?
- A. Thighs and hips
- B. Forearms and hips
- C. Thighs and abdomen
- D. Abdomen and buttocks
Correct Answer: C
Rationale: Rotating injections between the thighs and abdomen minimizes tissue damage and ensures consistent absorption.
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
- A. Examine pupil reactions to light.
- B. Assess level of consciousness.
- C. Observe for seizure activity.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.
Which potential pituitary complication should the nurse assess for in the client diagnosed with a traumatic brain injury (TBI)?
- A. Diabetes mellitus type 2 (DM 2).
- B. Seizure activity.
- C. Syndrome of inappropriate antidiuretic hormone (SIADH).
- D. Cushing's disease.
Correct Answer: C
Rationale: TBI can damage the pituitary, causing SIADH (C), leading to fluid retention and hyponatremia. DM2 (A) is unrelated, seizures (B) are neurological, and Cushing’s (D) is less common post-TBI.
A family member brings the client to the emergency department reporting that the 78-year-old father has suddenly become very confused and thinks he is living in 1942, that he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member?
- A. Has your father been diagnosed with dementia?'
- B. What medication has your father taken today?'
- C. What have you given him that makes him think it's poison?'
- D. Does your father like to watch old movies on television?'
Correct Answer: B
Rationale: Sudden confusion and delusions suggest delirium, often medication-related. Asking about medications (B) identifies potential causes. Dementia (A) causes gradual decline, blaming poison (C) is untherapeutic, and movies (D) are irrelevant.