Nokea
Which of the following statements by a client indicates adequate understanding of preparation for electroencephalography?
- A. I cannot eat or drink after midnight.'
- B. I need to wash my hair before the test.'
- C. I need to remove metal jewelry.'
- D. I cannot take aspirin before the test.'
Correct Answer: B
Rationale: The client needs to wash his hair to remove hair spray, cream, or oil that might interfere with attaching the electrodes to the scalp. Food or fluids do not need to be restricted, with the exception of caffeinated fluids. There is no restriction on metal objects. Aspirin is not a medication that needs to be held before the test (just anticonvulsants, tranquilizers, barbiturates, and other sedatives).
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All of the following should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids.
- B. administer oxygen.
- C. decrease maternal fluids.
- D. turn the mother.
Correct Answer: C
Rationale: Decreasing maternal fluids is the only intervention that should not be performed when fetal distress is indicated.
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
- A. Brown-Séquard syndrome
- B. posterior cord syndrome
- C. central cord syndrome
- D. cauda equina syndrome
Correct Answer: A
Rationale: Brown-Séquard syndrome is a result of damage to one-half of the spinal cord. The other choices are also incomplete lesions of the spinal cord, but they have different defining characteristics.
Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct Answer: B
Rationale: The epileptic client is at risk for injury due to the complications of seizure activity, such as possible head trauma associated with a fall. The other choices are not related to the question.
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Restraints must be released every 2 hours to assess circulation, skin integrity, and client comfort, with assessments every 30 minutes while restrained.
Which of the following statements by an adult child of a client with late-stage Alzheimer's disease indicates a need for further teaching by the nurse?
- A. I should provide a regular schedule for toileting
- B. I should talk to my father less because he can't communicate
- C. I should give my father oral care after every meal and bedtime
- D. I should assist my father with eating and drinking
Correct Answer: B
Rationale: Communication through talking and touching remains important for Alzheimer's clients, even if they can't respond, to provide comfort and connection. The other statements reflect appropriate care.