Nokea
Which nursing intervention is best during the confusedness?
- A. Reading a newspaper or magazine to the client
- B. Informing the client that confusion is temporary
- C. Withholding verbal communication temporarily
- D. Reorienting the client to place and situation
Correct Answer: D
Rationale: Reorienting the client to place and situation reduces confusion and promotes safety post-craniotomy.
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The client is diagnosed with a brain abscess. Which sign/symptom is the most common?
- A. Projectile vomiting.
- B. Disoriented behavior.
- C. Headaches, worse in the morning.
- D. Petit mal seizure activity.
Correct Answer: C
Rationale: Brain abscesses cause increased ICP, leading to headaches worse in the morning (C). Vomiting (A) is less specific, disorientation (B) is secondary, and petit mal seizures (D) are less common.
The home health nurse evaluates the foot care of the dark-skinned African client who has peripheral neuropathy. Which client actions in providing foot care are appropriate? Select all that apply.
- A. Uses a mirror and visually inspects the feet on a daily basis
- B. Lotions the feet and legs daily, avoiding between the toes
- C. Goes barefoot when indoors to help dry and air out the feet
- D. Wears warm socks and boots when outside in cold weather
- E. Trims toenails weekly so they have a rounded contour
- F. Inspects the feet for redness and other signs of inflammation
Correct Answer: A,B,D
Rationale: Using a mirror allows for visual inspection of the bottom of the feet and between the toes for areas of skin breakdown. Keeping the skin adequately lubricated with lotion prevents drying and cracking. Lotion should not be applied between the toes because it increases moisture and the risk for infection. Clients should avoid going barefoot because this increases the risk for foot injury. Wearing appropriate clothing protects the skin from injury because sensation is diminished with peripheral neuropathy. Toenails should be trimmed straight across to avoid damaging the tissue, which is slow to heal in the presence of peripheral neuropathy. In a dark-skinned client, areas of inflammation may appear purplish-blue or violet rather than appearing reddened (erythematous).
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
- A. Social worker.
- B. Chaplain.
- C. Health-care provider.
- D. Occupational therapist.
Correct Answer: A
Rationale: A social worker (A) can connect the family with community resources, financial aid, and support services. Chaplains (B) address spiritual needs, providers (C) focus on medical care, and occupational therapists (D) address functional deficits.
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.