Nokea
Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'
- A. Explain to the client, 'Your mother died several years ago.'
- B. Tell the client, 'Your mother will visit later.'
- C. State, 'You miss your mother. What was she like?'
- D. Ask the client, 'When did you last see your mother?'
Correct Answer: C
Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.
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When the nurse monitors the client's neurologic status, which finding is most suggestive that the client's intracranial pressure is increasing?
- A. Widening pulse pressure
- B. Increased respiratory rate
- C. Elevated temperature
- D. Decreased level of consciousness
Correct Answer: A
Rationale: Widening pulse pressure is a hallmark sign of increasing intracranial pressure, often accompanied by bradycardia (Cushing's triad).
The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
- A. The elderly client who is experiencing a stroke in evolution.
- B. The client diagnosed with a transient ischemic attack 48 hours ago.
- C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
- D. The client with Alzheimer's disease who is wandering in the halls.
Correct Answer: A
Rationale: A stroke in evolution (A) is an acute, progressing condition requiring experienced monitoring. TIA (B) is stable, Guillain-Barré pain (C) is manageable, and wandering (D) needs supervision but is less acute.
The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump?
Correct Answer: 20 mL/hr
Rationale: Calculate: (1,000 units/hr ÷ 25,000 units) × 500 mL = 20 mL/hr. The pump should be set to 20 mL/hr.
Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply.
- A. Position the client with the head of the bed up 30 degrees.
- B. Cluster activities of care.
- C. Suction the client every three (3) hours.
- D. Administer soapsuds enemas until clear.
- E. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: HOB at 30 degrees (A) promotes venous drainage, reducing ICP. Clustering activities (B) increases ICP, suctioning every 3 hours (C) is excessive, enemas (D) are irrelevant, and Trendelenburg (E) worsens ICP.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first?
- A. Notify the health-care provider immediately.
- B. Prepare to administer an antihistamine.
- C. Test the drainage for presence of glucose.
- D. Place a 2 x 2 gauze under the nose to collect drainage.
Correct Answer: C
Rationale: Clear nasal drainage post-head injury may indicate cerebrospinal fluid (CSF) leak, confirmed by testing for glucose (C). This is the first step to guide further action. Notifying the provider (A) follows confirmation, antihistamines (B) are irrelevant, and gauze (D) is a secondary measure.