Nokea
Which of the following nursing interventions should be done in the case of a client who has a head injury obtained from being thrown off of a motorcycle?
- A. Assess LOC every hour or more often if needed
- B. Put the code cart outside the client's room
- C. Keep the client quiet in bed
- D. Allow one visitor at a time
Correct Answer: A
Rationale: Frequent assessments of LOC are critical to detect worsening neurological status.
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The nurse plans to encourage the paraplegic patient to drink plenty of fluids mainly because increased fluid intake
- A. replaces fluid lost during periods of increased perspiration
- B. decreases renal calculi formation
- C. tends to decrease the possibility of spinal shock
- D. will decrease the tendency for constipation
Correct Answer: D
Rationale: Increased fluids help prevent constipation in immobilized patients.
A diagnosis of a ruptured cerebral aneurysm has been made in a patient with manifestations of a stroke. The nurse anticipates which treatment option that would be considered for the patient?
- A. Hyperventilation therapy
- B. Surgical clipping of the aneurysm
- C. Administration of hyperosmotic agents
- D. Administration of thrombolytic therapy
Correct Answer: B
Rationale: Surgical clipping prevents further bleeding from a ruptured aneurysm
In planning Mr. Smith's preoperative care to minimize the risk of an acute exacerbation, it will be most important to include
- A. discussion of postoperative care
- B. arrangements with dietary department to increase protein intake
- C. increased active and passive range-of-motion exercises
- D. time for Mr. Smith to share his feelings about the impending surgery
Correct Answer: C
Rationale: Exercise helps maintain joint function and reduces the risk of exacerbation.
The earliest indication that Mr. Smith is developing increasing intracranial pressure is
- A. decreasing level of consciousness
- B. increasing systolic blood pressure
- C. slowing of respirations
- D. decreasing pulse rate
Correct Answer: A
Rationale: A decreasing level of consciousness is often the first sign of increased intracranial pressure.
Nurse Peterson is reviewing her notes on various neurological conditions to prepare for an upcoming training session. She focuses on a chronic, degenerative, progressive disease of the central nervous system, notable for small patches of demyelination in the brain and spinal cord. Which disease is Nurse Peterson studying?
- A. Huntington's disease
- B. Parkinson's disease
- C. Creutzfeldt-Jakob's disease
- D. Multiple sclerosis
Correct Answer: D
Rationale: Multiple sclerosis is characterized by demyelination in the central nervous system, leading to a variety of neurological symptoms.