A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by: A. Introducing ice water into the external auditory canal. B. Touching the cornea with a wisp of cotton. C.… Read More »
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D. Urinary continence Correct Answer: B. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock.… Read More »
A 78-year-old client is admitted to the emergency department with numbness and weakness of the left arm and slurred speech. Which nursing intervention is a priority? A. Prepare to administer recombinant tissue plasminogen activator (rt-PA). B. Discuss the precipitating factors that caused the symptoms. C. Schedule for A STAT computer tomography (CT)… Read More »
The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following? A. Cerebellar function B. Intellectual function C. Cerebral function D. Sensory function Correct Answer: C. Cerebral function The mental status examination assesses functions… Read More »
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. B. Rapid Dilantin administration can cause cardiac arrhythmias. C. Dilantin should be mixed in dextrose in water before… Read More »
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure? A. Side-lying, with legs pulled up and head bent down onto the chest. B. Side-lying, with a pillow under the hip. C. Prone, in a slight Trendelenburg’s position. D.… Read More »
While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition? A. The client may be less sensitive to the effects of a neuromuscular blocking agent. B. Succinylcholine shouldn’t be used; pancuronium may be… Read More »
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli Correct Answer: D. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction,… Read More »
A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: A. A cerebral lesion… Read More »
A male client is color blind. The nurse understands that this client has a problem with: A. Rods. B. Cones. C. Lens. D. Aqueous humor. Correct Answer: B. Cones. Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of… Read More »