Nokea
Which response by the nurse is most appropriate?
- A. Clipping the hair is hospital policy.'
- B. This method is better for you.'
- C. Shaving the head causes microscopic cuts, resulting in risk for infection.'
- D. Surgery could be postponed if bleeding from the scalp occurs.'
Correct Answer: C
Rationale: Clipping avoids microscopic cuts from shaving, reducing infection risk, which is critical for craniotomy.
You may also like to solve these questions
When planning care for this client, which equipment is most important for the nurse to keep at the bedside?
- A. A cardiac defibrillator in case of cardiac arrest
- B. A suction machine in case of compromised swallowing
- C. A cooling blanket in case of hyperthermia
- D. An IV infusion pump for fluid administration
Correct Answer: B
Rationale: A suction machine is essential to clear secretions in myasthenia gravis clients with compromised swallowing, preventing aspiration.
The 85-year-old client diagnosed with a stroke is complaining of a severe headache. Which intervention should the nurse implement first?
- A. Administer a nonnarcotic analgesic.
- B. Prepare for STAT magnetic resonance imaging (MRI).
- C. Start an intravenous infusion with D5W at 100 mL/hr.
- D. Complete a neurological assessment.
Correct Answer: D
Rationale: A severe headache in a stroke patient may indicate complications like hemorrhagic transformation or increased intracranial pressure. A neurological assessment (D) is the first step to evaluate the cause and guide further actions. Analgesics (A) may mask symptoms, MRI (B) requires assessment first, and IV fluids (C) are not urgent.
The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
- A. A 55-year-old African American male.
- B. An 84-year-old Japanese female.
- C. A 67-year-old Caucasian male.
- D. A 39-year-old pregnant female.
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.