MedSurg: Prioritization Ch 7 Neurological

The nurse is caring for clients in the emergency department. Which client should the nurse assess first? 1. The client with an epidural hematoma. 2. The client who had a seizure who is in the postictal state. 3. The client diagnosed with R/O encephalitis who has a headache. 4. The client with multiple sclerosis who has scanning speech.

Correct answer: 1 1. An epidural hematoma results from bleeding between the dura and the inner surface of the skull, and is a medical emergency. This client should be seen first. 2. Postictal state is a sleepy state the client has after having a seizure. This client is stable; therefore, this client does not have to be assessed first. 3. The client with encephalitis may have fever, headache, nausea, and vomiting. The client needs to be assessed but not prior to a head injury with active arterial bleeding. 4. The client with multiple sclerosis is expected to have scanning speech; therefore, the nurse should not assess this client first.

The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse? 1. The elderly client who is experiencing a stroke in evolution. 2. The client diagnosed with a transient ischemic attack 48 hours ago. 3. The client diagnosed with Guillain-Barré syndrome who complains of leg pain. 4. The client with Alzheimer's disease who is wandering in the halls.

Correct answer: 1 1. Because the client is having an evolving stroke, the client is experiencing a worsening of signs/symptoms over several minutes to hours; thus, the client is at risk for dying and should be cared for by the most experienced nurse. 2. A transient ischemic attack by definition lasts less than 24 hours; thus, this client should be stable at this time. 3. Pain is expected in clients with Guillain-Barr? syndrome, and symptoms typically occur on the lower half of the body, which wouldn't affect the airway. Therefore, a less experienced nurse could care for this client. 4. The charge nurse could assign this client to an unlicensed assistive personnel (UAP).

The client being admitted with transient ischemic attack is complaining of a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse question? 1. Schedule for CT scan with contrast in a.m. 2. Administer acetaminophen 2 PO for headache. 3. Take client's vital signs per protocol. 4. Provide the client with a low-fat, low-cholesterol diet.

Correct answer: 1 1. The client is allergic to iodine; therefore, the client cannot have the CT scan with contrast because it is iodine. The nurse should question this HCP order. 2. The client is not allergic to Tylenol; therefore, this order should not be questioned. 3. The client should have vital signs taken; therefore, this order should not be questioned. 4. A low-fat, low-cholesterol diet would be appropriate for this client.

The nurse is administering medications on a neurological unit. Which medication should the nurse administer first? 1. The osmotic diuretic to the client with a closed head injury. 2. The morning medications to the client scheduled for physical therapy. 3. The narcotic pain medication to a client with increased intracranial pressure. 4. The anticonvulsant gabapentin (Neurontin) to the client with restless legs syndrome.

Correct answer: 1 1. The client with a closed head injury is at risk for increased intracranial pressure and the osmotic diuretic is a priority medication. 2. The nurse should administer the medications to the client prior to leaving the unit but the client with a physiological, potentially life-threatening complication is priority. 3. Before administering a narcotic, the nurse must first assess the client to make sure that administering the medication is not going to mask symptoms. 4. This is a routine medication and can be administered 30 minutes before or after the routine scheduled time. This is not a priority medication.

The nurse in a rehabilitation facility is evaluating the progress of a female client who sustained a C-6-C-7 spinal cord injury. Which outcome indicates the client is improving? 1. The client can maneuver the automatic wheelchair into the hallway. 2. The client states she will be able to return to work in a few weeks. 3. The client uses eye blinks to communicate yes and no responses. 4. The client's husband built a wheelchair ramp onto their house.

Correct answer: 1 1. The client's ability to maneuver a wheelchair indicates that the client has progressed in therapy. 2. This statement indicates the client is in denial about the prognosis of the injury. 3. Eye blinks may be used for communication in a client with a higher-level injury. 4. The building of a wheelchair ramp indicates the husband is preparing for the client's return home, not that the client is progressing in therapy.

The critical care charge nurse is making client assignments for the shift. Which client should the charge nurse assign to the graduate nurse who just completed the orientation? 1. The client with amyotrophic lateral sclerosis on a ventilator who is dying and whose family is at the bedside. 2. The client who has a closed head injury and has increasing intracranial pressure receiving intravenous osmitrol (Mannitol). 3. The client with a C-5 spinal cord injury who is experiencing spinal shock and is on the vasoconstrictor dopamine. 4. The client with a seizure disorder who has been experiencing status epilepticus for the past 24 hours.

Correct answer: 1 1. The less experienced nurse could care for the client on a ventilator and console the family as needed. This client is not in a life-threatening situation and is stable for the condition. 2. A client with increased intracranial pressure requires a more experienced critical care nurse. 3. This client is unstable and requires a more experienced critical care nurse. 4. Status epilepticus is a state of continuous seizure activity and is the most serious complication of epilepsy. This is a neurological emergency. This client should be assigned to a more experienced nurse.

The terminally ill client diagnosed with ALS (Lou Gehrig's disease) has a DNR order in place and is currently complaining of "pain all over." The nurse notes the client has shallow breathing and a P 67, R 8, B/P 104/62. Which intervention should the nurse implement? 1. Administer the narcotic pain medication IVP. 2. Turn and reposition the client for comfort. 3. Refuse to administer pain medication. 4. Notify the HCP of the client's vital signs.

Correct answer: 1 1. The nurse should administer the IVP narcotic pain medication even if the client has shallow breathing, with respirations of 8. A nurse should never administer a medication with the intent of hastening the client's death, but medicating a dying client to achieve a peaceful death is an appropriate intervention. 2. Repositioning the client would not be effective for "pain all over." 3. This is cruel to do to a client who is dying and has made himself or herself a DNR. 4. The HCP has all the orders needed in place. There is no reason to notify the HCP.

A wife tells the clinic nurse her husband had been fine and is now confused, doesn't know where he is, and is not acting like his usual self. Which intervention should the nurse implement first? 1. Perform a neurological assessment. 2. Notify the client's healthcare provider. 3. Ask the wife to explain more about the behavior. 4. Determine when the client last had something to eat.

Correct answer: 1 1. The nurse should first assess the client's neurological status. It is not normal for an elderly person to have a change in behavior; this is cause for assessment. 2. The nurse may need to notify the HCP but not prior to completing a neurological assessment. 3. The nurse should first assess the client prior to further interviewing the client's wife. 4. The nurse could determine the last time the client ate, since the confusion could be due to hypoglycemia, but the first intervention is to complete a neurological assessment.

The home health (HH) nurse is caring for a 22-year-old female client who sustained an L-5 spinal cord injury 2 months ago. The client says, "I will never be happy again. I can't walk, I can't drive, and I had to quit college." Which intervention should the nurse implement first? 1. Allow the client to ventilate her feelings of powerlessness. 2. Refer the client to the home healthcare agency social worker. 3. Recommend contacting the American Spinal Cord Association. 4. Ask the client whether she has any friends who come and visit.

Correct answer: 1 1. Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings. The client is still grieving over her loss, and the nurse should let her vent feelings. 2. The social worker may be able to help the client with driving and going back to college, but this is not the nurse's first intervention. 3. The American Spinal Cord Association is an excellent resource for clients with spinal cord injuries, but the client is still grieving, and the nurse should allow the client to express her feelings. 4. Attempting to help identify a support system for the client is an appropriate intervention, but the first intervention is to allow the client to vent her feelings.

The rehabilitation nurse is planning the discharge of a 68-year-old client whose status post-subarachnoid hemorrhage includes residual speech and balance deficits. Which referral should the nurse initiate at this time? 1. Referral to a hospice organization. 2. Referral to the speech therapist. 3. Referral to the physical therapist. 4. Referral to a home health agency.

Correct answer: 4 1. A hospice organization is designed for terminally ill clients. The client is not terminally ill. 2. The speech therapist helps clients regain speech and swallowing abilities. This therapy should have been occurring while the client was in the rehab facility. 3. The physical therapist assists the client with gait and muscle strengthening. This therapy should have been occurring while the client was in the rehab facility. 4. The client is being discharged. The nurse should plan for continuity of care by arranging for a home health agency to follow the client at home.

The client diagnosed with a cerebrovascular accident (CVA) has residual right-sided hemiparesis and difficulty swallowing, but is scheduled for discharge. Which referral is most appropriate for the case manager to make at this time? 1. Inpatient rehabilitation unit. 2. Home healthcare agency. 3. Long-term care facility. 4. Outpatient therapy center.

Correct answer: 1 1. This client should be referred to an inpatient rehabilitation facility for intensive therapy before deciding on long-term placement (home with home healthcare or a long-term care facility). The initial rehabilitation a client receives can set the tone for all further recuperation. This is the appropriate referral at this time. 2. A home healthcare agency may be needed when the client returns home, but the most appropriate referral is to a rehabilitation center where intensive therapy can take place. 3. A long-term care facility may be needed at some point, but the client should be given the opportunity to regain as much lost ability as possible at this time. 4. The outpatient center would be utilized when the client is ready for discharge from the inpatient center.

Which client should the charge nurse assess first after receiving the change-of-shift report? 1. The client with a C-6 SCI who is complaining of dyspnea and has a respiratory rate of 12 breaths/minute. 2. The client with an L-4 SCI who is frightened about being transferred to the rehabilitation unit. 3. The client with an L-2 SCI who is complaining of a headache and feeling very hot all of a sudden. 4. The client with a C-4 SCI who is on a ventilator and has a pulse oximeter reading of 98%.

Correct answer: 1 1. This client with dyspnea and a respiration rate of 12 has signs/symptoms of a respiratory complication and should be assessed first because ascending paralysis at the C-6 level could cause the client to stop breathing. 2. This is a psychosocial need and should be addressed, but it is not priority over a physiological problem. 3. A client with a lower SCI would not be at risk for autonomic dysreflexia; therefore, a complaint of headache and feeling hot would not be priority over an airway problem. 4. The client with a pulse oximeter reading greater than 93% is receiving adequate oxygenation.

The charge nurse observes the client's nurse telling the unlicensed assistive personnel (UAP) to feed an elderly client diagnosed with a cerebrovascular accident (CVA). Which question should the charge nurse ask the client's nurse? 1. "How does the client swallow the medications?" 2. "Did you complete your head to toe assessment?" 3. "Does the client have some Thick-It in the room?" 4. "Why would you delegate feeding to a UAP?"

Correct answer: 1 1. This question will determine whether the nurse has assessed the client's ability to swallow. The nurse cannot delegate unstable clients, and a client newly diagnosed with a CVA may be unstable and have difficulty swallowing. 2. This question does not address the client's ability to swallow. 3. Thick-It might be needed if the client has difficulty swallowing, but the charge nurse has not established that the client has swallowing difficulty. 4. A UAP can feed clients who are stable and do not require nursing judgment during the process.

The clinic nurse is making assignments for the large family practice clinic. Which task should be assigned to the staff nurse who is 4 months pregnant? 1. Have the staff nurse answer the telephone calls from clients. 2. Instruct the staff nurse to work in the radiology department. 3. Tell the staff nurse to work in the front desk triage area. 4. Assign the staff nurse to work in the oncology clinic.

Correct answer: 1 1. This would be the most appropriate assignment because the nurse would not be exposed to any contagious diseases or dangerous radiological procedures. 2. The pregnant nurse should not be exposed to x-rays, which could endanger the fetus. 3. Working in the front desk triage area would allow the pregnant nurse to be exposed to any type of contagious or infectious disease. This is not an appropriate assignment. 4. The oncology clinic will have clients receiving chemotherapeutic agents that may endanger the fetus; this would not be the most appropriate assignment. Even if the nurse is not administering the medication, the most appropriate assignment is to assign the nurse to an area that poses no danger to the fetus.

The nurse is caring for a client diagnosed with Alzheimer's disease. Which nursing tasks should not be delegated to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Check the client's skin under the restraints. 2. Administer the client's antipsychotic medication. 3. Perform the client's morning hygiene care. 4. Ambulate the client to the bathroom. 5. Obtain the client's routine vital signs.

Correct answer: 1 and 2 1. Checking the client's skin involves assessment; therefore, the nurse cannot delegate this assignment to the UAP. 2. The nurse cannot delegate medication administration to a UAP. 3. The UAP can perform routine hygiene care. The nurse must then make the time to assess the client's skin. 4. The UAP can ambulate a client to the bathroom. 5. The UAP can take routine vital signs.

The client diagnosed with a right-sided cerebral vascular accident (CVA), or brain attack, is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply. 1. Position the client to prevent shoulder adduction. 2. Refer the client to occupational therapy daily. 3. Encourage the client to move the affected side. 4. Perform quadriceps exercises five times a day. 5. Instruct the client to hold the fingers in a fist.

Correct answer: 1, 2, 3, 4 1. Placing a small pillow under the shoulder will prevent the shoulder from adducting toward the chest and developing a contracture. 2. The client should be referred to occupational therapy for assistance with performing activities of daily living (ADLs). 3. The client should not ignore the paralyzed side, and the nurse must encourage the client to move it as much as possible; a written schedule may assist the client in exercising. 4. These exercises should be done at least five times a day for 10 minutes at a time to help strengthen the muscles used for walking. 5. The fingers should be positioned so that they are barely flexed, to prevent contracture.

The 19-year-old client is in the rehabilitation unit following a traumatic brain injury. Which intervention should the nurse delegate to the unlicensed assistive personnel (UAP)? Select all that apply. 1. Make safety rounds hourly. 2. Refer the client to a college and career counselor. 3. Assist the client with meals. 4. Clamp and unclamp the indwelling catheter every 2 hours. 5. Discuss discharge placement with the parents.

Correct answer: 1, 3, and 4 1. The UAP can make hourly rounds on the client, taking the client to the bathroom, giving the client a drink of water, checking to make sure the client is not climbing out of bed, etc. 2. This is the responsibility of the registered nurse or the social worker. 3. This client is in rehab and should be stable so that the UAP can set up the tray or feed the patient. 4. The UAP can clamp and unclamp an indwelling catheter in a rehab area. This is a non-invasive skill that can be taught to the UAP. It does not require judgment. 5. This is the responsibility of the registered nurse or the social worker.

The nurse in a long-term care facility is administering medications to a group of clients. Which medication should the nurse administer first? 1. Acetylsalicylic acid (aspirin) to a client diagnosed with cerebrovascular disease. 2. Neostigmine (Prostigmin) to a client diagnosed with myasthenia gravis. 3. Cephalexin (Keflex) to a client diagnosed with an acute urinary tract infection. 4. Acyclovir (Zovirax) to a client diagnosed with Bell's palsy.

Correct answer: 2 1. A daily aspirin is not a priority medication. This medication can be administered within 30 minutes before or 30 minutes after the scheduled time. 2. Prostigmin promotes muscle function in clients diagnosed with myasthenia gravis. This medication should always be administered on time to prevent loss of muscle tone, especially the muscles of the upper respiratory tract. This is the priority medication to administer at this time. 3. An oral antibiotic can be administered within 30 minutes before or after the scheduled time frame. 4. Acyclovir (Zovirax) alone or in combination with predisone may be used to treat Bell's palsy but this medication is not a priority medication.

The nurse in a long-term care facility is developing the plan of care for a client diagnosed with end-stage Alzheimer's disease. Which client problem is priority for this client? 1. Inability to do activities of daily living. 2. Increased risk for injury. 3. Potential for constipation. 4. Ineffective family coping.

Correct answer: 2 1. Clients diagnosed with Alzheimer's disease may have problems with completing activities of daily living, but this is not the client's priority problem. 2. Safety is the highest priority for clients diagnosed with end-stage Alzheimer's disease because the client is unaware of his or her own surroundings and can easily wander from an area of safety. 3. The client in end-stage disease may have an increased risk for constipation, but this is not priority over safety of the client. 4. The client's family is often distraught over seeing their loved one deteriorate because of Alzheimer's, but it is not priority over the safety of the client.

The employee health nurse is caring for a male employee who reports tripping and is complaining of right knee pain. There is no visible injury, and the client has a normal neurovascular assessment. Which intervention should the nurse implement? 1. Request the employee to return to work. 2. Obtain a urine specimen for a drug screen. 3. Send the client to the emergency department. 4. Place a sequential compression device on the leg.

Correct answer: 2 1. If a client is complaining of pain, the nurse should not ask the client to return to work. If nothing else, the client should be allowed to stay in the clinic until the pain subsides. 2. The employee must submit to a urine drug screen anytime there is an injury. This is standard practice by many employers to help determine whether the employee was under the influence during the time of the accident. Workers' compensation will not be responsible if the employee is under the influence of alcohol or drugs. 3. Because there are no visible injuries and the neurovascular assessment is normal, a referral to the emergency department is not warranted. The employee health nurse could send the employee home with further instructions. None of the complaints warrants the employee's needing an x-ray. 4. A sequential compression device is used to help prevent deep vein thrombosis for clients on bed rest. This is not an appropriate intervention.

Which task is most appropriate for the clinic nurse to delegate to the unlicensed assistive personnel (UAP)? 1. Request the UAP to ride in the ambulance with a client. 2. Ask the UAP to escort the client in a wheelchair to the car. 3. Instruct the UAP to show the client how to use crutches. 4. Tell the UAP to call the pharmacy to refill a prescription.

Correct answer: 2 1. If the client must be transferred from the clinic to the hospital, then the client is unstable and therefore should not be assigned to a UAP. 2. The client is stable because he or she is being sent home; therefore, the UAP could safely complete this task. 3. Showing the client how to walk with crutches is teaching, and the nurse cannot delegate teaching to the UAP. 4. The UAP should not be calling a pharmacy because this is not within the scope of practice of unlicensed personnel. The HCP is responsible for delegating this task.

The intensive care unit nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis secondary to a cerebrovascular accident. Which action by the UAP requires the nurse to intervene? 1. The UAP performs passive range-of-motion (ROM) exercises for the client. 2. The UAP places the client on the abdomen with the head to the side. 3. The UAP uses a lift sheet when moving the client up in bed. 4. The UAP praises the client for attempting to feed him- or herself.

Correct answer: 2 1. It would be appropriate for the UAP to perform ROM exercises to help prevent contractures; therefore, this action would not require the nurse to intervene. 2. This is not an appropriate intervention because the client is at risk for increased intracranial pressure (ICP); therefore, the client should not be placed on the stomach. The prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures, and done in rehabilitation. 3. The client should be pulled up in bed by placing the arm underneath the back or using a lift sheet; therefore, the nurse would not need to intervene. 4. The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair, brushing teeth, or feeding him- or herself. The nurse would not need to intervene.

The critical care nurse is caring for a client with a head injury secondary to a motorcycle accident who, on morning rounds, is responsive to painful stimuli and assumes decorticate posturing. Two hours later, which data would warrant immediate intervention by the nurse? 1. The client has purposeful movement when the nurse rubs the sternum. 2. The client extends the upper and lower extremities in response to painful stimuli. 3. The client is aimlessly thrashing in the bed when a noxious stimulus is applied. 4. The client is able to squeeze the nurse's hand on a verbal request.

Correct answer: 2 1. Purposeful movement following painful stimuli would indicate an improvement in the client's condition and would not warrant intervention by the nurse. 2. Extension of the upper and lower extremities is assuming a decerebrate posture, which indicates the client's intracranial pressure (ICP) is increasing. This would warrant immediate intervention by the nurse. 3. Aimless thrashing would indicate an improvement in the client's condition and would not warrant intervention by the nurse. 4. If the client is able to follow simple commands, then the client's condition is improving and would not warrant intervention by the nurse.

The home health (HH) nurse is admitting a female client diagnosed with myasthenia gravis. The client tells the nurse, "Even with my medication I get exhausted when I do anything." Which intervention should the nurse implement? 1. Talk to the client's husband about helping around the house more. 2. Contact the HH occupational therapist to discuss the client's concern. 3. Allow the client to verbalize her feelings of being exhausted. 4. Recommend the client make an appointment with her HCP.

Correct answer: 2 1. The client has a chronic illness. The nurse should empower the client to deal with her disease process, not put more responsibility on her husband. 2. The occupational therapist could assist the client in identifying ways to save energy when performing activities of daily living. Myasthenia gravis is a neurological condition that causes skeletal muscle weakness. 3. The HH nurse should realize that exhaustion is a symptom of her disease process and should utilize any member of the home healthcare team who could help the client. Allowing the client to verbalize her feelings about exhaustion is an appropriate therapeutic intervention, but this client needs specific advice on how to handle her exhaustion. 4. If the client is taking her medication, she does not need to be referred to her HCP. Myasthenia gravis is a chronic illness, and muscle weakness is the primary symptom.

The nurse and LPN are caring for a client diagnosed with a stroke. Which intervention should the nurse assign to the LPN? 1. Feed the client who is being allowed to eat for the first time. 2. Administer the client's anticoagulant subcutaneously. 3. Check the client's neurological signs and limb movement. 4. Teach the client to turn the head and tuck the chin to swallow.

Correct answer: 2 1. The nurse should be the first one to feed the client in order for the nurse to evaluate the client's ability to swallow and not aspirate. 2. The LPN could administer routine parenteral medications. This is the best task to assign to the LPN. 3. This involves assessing the client; therefore, the nurse should not delegate this assignment to the LPN. 4. Teaching is the responsibility of the RN.

The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barré syndrome who has ascending paralysis to the knees. 2. The client with a C-6 spinal cord injury who has autonomic dysreflexia. 3. The client with Parkinson's disease who is experiencing "pill rolling." 4. The client with Huntington's disease who has writhing, twisting movements of the face.

Correct answer: 2 1. The nurse would expect the client with Guillain-Barr? syndrome to have ascending paralysis and the problem has just reached the knees, so the nurse should not need to assess this client first. 2. The client with a C-6 SCI is expected to have autonomic dysreflexia but it is an emergency situation; therefore, the nurse should assess this client first. 3. "Pill rolling," a hand tremor wherein the thumb and forefinger appear to move in a rotary fashion as if rolling a pill, is an expected clinical manifestation of Parkinson's; therefore, the nurse would not assess this client first. 4. The client with Huntington's disease has chorea, which includes abnormal and excessive involuntary movements; therefore, this client would not be assessed first.

The nurse caring for a client is accidentally stuck with the stylet used to start an IV infusion. The nurse flushes the skin with water and tries to get the area to bleed. Which action should the nurse implement next? 1. Have the laboratory draw the client's blood. 2. Notify the charge nurse and complete the incident report. 3. Contact the employee health nurse to start prophylactic medication. 4. Follow up with the employee health nurse to have lab work drawn.

Correct answer: 2 1. This should be done but not prior to notifying the charge nurse and reporting the incident. 2. The nurse should notify the charge nurse first so the hospital protocol can be followed, including notifying the infection control nurse, completing an incident report, obtaining blood from the client, and starting prophylactic medication if warranted. 3. This should be done within 4 hours of the stick, but the charge nurse should be notified first so that proper hospital protocol can be initiated. 4. This is done at 3 months and 6 months.

The nurse is administering medications for clients on a neurological unit. Which medication should the nurse administer first? 1. A pain medication to a client complaining of a headache rated an 8 on 1 to 10 pain scale. 2. A steroid to the client experiencing an acute exacerbation of multiple sclerosis. 3. An anticholinesterase medication to a client diagnosed with myasthenia gravis. 4. An antacid to a client with pyrosis who has called several times over the intercom.

Correct answer: 3 1. A pain medication is important to administer in a timely manner, but its administration is not priority over a medication that must be administered on time to prevent respiratory complications. 2. A steroid medication is not priority over a client who may experience respiratory difficulty. Steroids must be given to prevent adrenal sufficiency but it does not have to be administered first. 3. Anticholinesterase medications administered for myasthenia gravis must be administered on time to preserve muscle functioning, especially the functioning of the muscles of the upper respiratory tract. {This is the priority medication.} 4. Clients who have called for medications should be attended to, but this client would not receive an antacid for heartburn before the client diagnosed with myasthenia gravis or the client in pain.

The charge nurse is making rounds and notices that the sharps container in the client's room is above the fill line. Which action should the charge nurse implement? 1. Complete an adverse occurrence report. 2. Discuss the situation with the primary nurse. 3. Instruct the UAP to change the sharps container. 4. Notify the infection control nurse immediately.

Correct answer: 3 1. An adverse occurrence report is completed for incidents occurring to clients. 2. The nurse should talk to the primary nurse, but the sharps container should be changed immediately. 3. The UAP can change a sharps container. This must be done because a sharps container above the fill line is a violation of Occupational Safety Health Administration (OSHA) rules and can result in a financial fine. 4. The infection control nurse does not need to be notified of this situation.

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene? 1. The UAP places the gait belt around the client's waist prior to ambulating. 2. The UAP places the client on the abdomen with the client's head to the side. 3. The UAP places her hand under the client's right axilla to help the client move up in bed. 4. The UAP praises the client for performing activities of daily living independently.

Correct answer: 3 1. Placing a gait belt prior to ambulating is an appropriate action for safety and would not require the nurse to intervene. 2. Placing the client in a prone position helps promote hyperextension of the hip joints, which is essential for normal gait and helps prevent knee and hip flexion contractures; therefore, this would not require the nurse to intervene. 3. This action is inappropriate and would require intervention by the nurse because pulling on a flaccid shoulder joint could cause shoulder dislocation; the client should be pulled up by placing the arm underneath the client's back or using a lift sheet. 4. The client should be encouraged and praised for attempting to perform any activities independently, such as combing hair or brushing teeth.

The client with a C-6 spinal cord injury (SCI) comes to the emergency department complaining of a throbbing headache and has a B/P of 200/120. Which intervention should the nurse implement first? 1. Place the client on a telemetry unit. 2. Complete a neurological assessment. 3. Insert an indwelling urinary catheter. 4. Request a STAT CT scan on the head.

Correct answer: 3 1. The client is experiencing autonomic dysreflexia, a complication of SCI above the T6, and the most common cause is a full bladder. Placing the client on telemetry is not the nurse's first intervention. 2. Completing a neurological assessment is an intervention a nurse could implement, but it should not be the first for a client experiencing autonomic dysreflexia. 3. Autonomic dysreflexia is a life-threatening condition and can be considered a medical emergency requiring immediate attention. The nurse should not assess but should intervene, and the most common cause is a full bladder. 4. A CT scan of the head would be appropriate if the elevated B/P was secondary to a CVA, not due to a complication of a SCI.

The client diagnosed with a cerebrovascular accident (CVA) is confined to a wheelchair for most of the waking hours. Which intervention is priority for the nurse to implement? 1. Encourage the client to move the buttocks every 2 hours. 2. Order a high-protein diet to prevent skin breakdown. 3. Get a pressure-relieving cushion to place in the wheelchair. 4. Refer the client to physical therapy for transfer teaching.

Correct answer: 3 1. The client should be encouraged to move the buttocks to increase blood circulation to the area, but a wheelchair cushion used every time the client is in the wheelchair will help prevent pressure ulcers. 2. A high-protein diet will assist with maintaining a positive nitrogen balance that will support wound healing, but it will not prevent pressure from causing a breakdown of the skin. 3. All clients remaining in a wheelchair for extended periods of time should have a wheelchair cushion that relieves pressure to prevent skin breakdown. 4. The more the client can move from the wheelchair to a chair to the bed, the more it will help decrease the possibility of a pressure ulcer, but a wheelchair cushion helps relieve pressure continuously.

The wife of a client diagnosed with a brain tumor tells the nurse, "I don't know how I will make it if something happens to my husband. I love him so much." Which statement is most appropriate for the nurse? 1. "I will call the chaplain to come and talk to you." 2. "Do you have any family support to be with you?" 3. "You don't know how you will make it if something happens." 4. "Do not worry, everything will be all right. You are a strong woman."

Correct answer: 3 1. The nurse should address the client's comment and not "pass the buck" to someone else. 2. The nurse should address the client's statement and not attempt to problem-solve at this point in the conversation. 3. The nurse is reflecting the client's comments, which will encourage the client to ventilate her feelings. This is the most appropriate response. 4. This is false reassurance and an inappropriate response to the client's statement.

The client in a multiple car crash dies in the emergency department. Which priority intervention should the emergency department nurse implement when addressing the needs of the client's family? 1. Ask if the client wanted to be a tissue donor. 2. Give the family the client's personal belongings. 3. Escort the family to a private room to grieve. 4. Determine which funeral home should be contacted.

Correct answer: 3 1. The nurse should ask if the client wishes to be a tissue donor but the priority intervention is to address the family's grieving. 2. The nurse should give the client's personal belongings to the family but the priority intervention is to address the family's grieving. 3. The nurse's priority intervention should be to address the grieving process of the family. 4. The client's body will have to be sent to a funeral home but it is not the nurse's priority intervention.

The nurse is the first person on the scene of a motor vehicle accident. The driver is in the driver's seat unconscious. Which action should the nurse implement first? 1. Stabilize the driver's cervical spine. 2. Do not move the client from the accident. 3. Ensure the driver has a patent airway. 4. Control any external bleeding.

Correct answer: 3 1. The nurse should stabilize the client's cervical spine to help prevent a spinal cord injury or the patient's spine can sustain irreparable damage during movement. 2. Unless the driver is in danger (car on fire or in water) the nurse should not move the driver. 3. The nurse should first ensure a patent airway. According to Maslow's Hierarchy of Needs, airway is always priority. 4. The nurse should control external bleeding but the first intervention is airway.

The clinic nurse is triaging client's telephone calls. Which client should the nurse call first? 1. The client diagnosed with AIDS who has developed Kaposi's sarcoma. 2. The client diagnosed with dementia who is having difficulty dressing himself. 3. The client with trigeminal neuralgia who is having lightening-like shock to the cheeks. 4. The client whose friend has botulism who has vomiting and abdominal cramping pain.

Correct answer: 4 1. A client with AIDS would be expected to have Kaposi's sarcoma; therefore, this client would not need to be visited first. 2. A client with dementia would be expected to have difficulty dressing; therefore, this client would not need to be visited first. 3. The classic feature of trigeminal neuralgia is excruciating pain described as a burning, knife-like, or lightning-like shock in the lips, upper or lower gums, cheek, forehead, or side of the nose. The nurse would not return this call first since the client is experiencing the normal signs/symptoms for the disease process. 4. Botulism is the most serious type of food poisoning and the client is exhibiting signs/symptoms of it; therefore, the nurse should return this phone call first.

The home health (HH) nurse is scheduling visits for the day. Which client should the nurse visit first? 1. The client with an L-4 SCI who is complaining of a severe, pounding headache. 2. The client with amyotrophic lateral sclerosis (ALS) who is depressed and wants to die. 3. The client with Parkinson's disease who is walking with a short, shuffling gait. 4. The client with a C-5 SCI who reports redness and drainage at the Halo vest sites.

Correct answer: 4 1. A severe, pounding headache would be priority for a client with a T-6 or above spinal cord injury (SCI) because it could be autonomic dysreflexia, but not in a client with a lower-level lesion. 2. The client's psychosocial need is not priority over clients with physiological problems. This client should not be visited first. 3. The client with Parkinson's disease is expected to have a short, shuffling gait; therefore, this client does not need to be seen first. 4. The client is reporting an infection at insertion sites into the bone, which can lead to osteomyelitis. This client is exhibiting a potentially life-threatening condition and should be seen first.

The community health nurse is triaging victims at the site of a disaster. Which client should the nurse categorize as black, priority 4? 1. The client who is alert and has a sucking chest wound. 2. The client who cannot stop crying and can't answer questions. 3. The client whose abdomen is hard and tender to the touch. 4. The client who has full thickness burns over 60% of the body.

Correct answer: 4 1. An alert client with a sucking chest wound should be categorized as red, priority 1, which means the injury is life threatening but survivable with minimal intervention. These clients can deteriorate rapidly without treatment. 2. A client who cannot stop crying and cannot answer questions should be categorized as green, priority 3, which means the injury is minor and treatment can be delayed hours to days. These clients should be moved away from the main triage area. Clients with behavioral and psychological problems are included in this category. 3. A client whose abdomen is hard and tender should be categorized as a yellow, priority 2, which means the injury is significant and requires medical care but can wait hours without threat to life or limb. Clients in this category receive treatment only after immediate casualties are treated. 4. This client should be categorized as black, priority 4, which means the injury is extensive and chances of survival are unlikely even with definitive care. Clients should receive comfort measures and be separated from other casualties, but not abandoned.

The nurse on the surgical unit is working with an unlicensed assistive personnel (UAP). Which task is most appropriate for the nurse to delegate to the UAP? 1. Change an abdominal dressing on a client who is 2 days postoperative. 2. Check the client's IV insertion site on the right arm. 3. Monitor vital signs on a client who has just returned from surgery. 4. Escort a client who has been discharged to the client's vehicle.

Correct answer: 4 1. The UAP cannot change abdominal dressings because the incision must be assessed for healing. 2. The UAP cannot check the client's IV site. Remember, check is "assess." 3. The nurse must monitor the vital signs on a client recently returned from surgery to determine whether the client is stable; the UAP can take vital signs and report results to the nurse. 4. The UAP can escort the client to the vehicle after discharge.

The 24-year-old client diagnosed with a traumatic brain injury is being transferred to a rehabilitation unit. Which healthcare provider order should the nurse question? 1. Physical therapy to work on lower extremity strength daily. 2. Occupational therapy to work on cognitive functioning bid. 3. A soft diet with mechanical ground meats and thickening agent in fluids. 4. Methylprednisolone (Solu-Medrol), a steroid, IVP q 6 hours.

Correct answer: 4 1. The client admitted to a rehabilitation unit is expected to participate in therapy for at least 3 hours each day. The nurse would not question this order. 2. The client admitted to a rehabilitation unit is expected to participate in therapy for at least 3 hours each day. The nurse would not question this order. 3. Clients with neurological deficits may have trouble swallowing. The nurse would not question this order. 4. A client in a rehabilitation unit for a brain injury should not require IV medications. The nurse should question this order.

The multidisciplinary team is meeting to discuss a client with right-sided weakness who has developed a Stage 2 pressure ulcer over the sacral area that is not healing. Which priority intervention should the client's home health (HH) nurse recommend? 1. Recommend the client get a hospital bed with a trapeze bar. 2. Recommend a home health aide provide care 7 days a week for the client. 3. Recommend the client be transferred to a skilled nursing unit. 4. Recommend a referral to the home healthcare agency wound care nurse.

Correct answer: 4 1. The client may benefit from a hospital bed, but this is not the priority intervention to address the client's non-healing pressure ulcer. 2. HH care agencies do not provide care 7 days a week. Even if the client could have an HH aide 7 days a week, it is not the priority intervention to address the client's non-healing pressure ulcer. 3. The client does not need to be transferred to a skilled nursing unit. The wound care nurse should attempt to heal the pressure ulcer in the home first. 4. The wound care nurse's primary role is to address non-healing pressure ulcers. This referral is the priority intervention.

The neurologist has explained to the family of a 22-year-old client with a traumatic brain injury placed on a ventilator after a motor vehicle accident that the client does not have any brain function. Which referral is appropriate at this time? 1. A local funeral director. 2. A hospice agency. 3. A home health nurse. 4. A tissue and organ bank.

Correct answer: 4 1. The family should designate a funeral home of their choice. The nurse does not make this referral. 2. Hospice is for clients who are dying, but this client is considered brain dead. 3. A home health nurse cannot help this client or family. 4. A 22-year-old client who experienced a traumatic brain death may be a good candidate for organ donation. Most tissue and organ banks prefer to be the ones to approach the family. This is the best referral.

The home health (HH) nurse enters the home of an 80-year-old female client who had a cerebrovascular accident (CVA), or "brain attack," 2 months ago. The client is complaining of a severe headache. Which intervention should the nurse implement first? 1. Determine what medication the client has taken. 2. Assess the client's pain on a pain scale of 1 to 10. 3. Ask whether the client has any acetaminophen (Tylenol). 4. Tell the client to sit down, and take her blood pressure.

Correct answer: 4 1. The nurse should determine what medication the client has taken, but the nurse should first attempt to determine whether the headache is secondary to high blood pressure. 2. No matter what number the client identifies on the pain scale in the home setting, the nurse must attempt to determine the cause. One way to try to determine the cause or to eliminate a possible cause is to take the client's blood pressure. 3. If the client's blood pressure is not elevated, the client could take the non-narcotic analgesic acetaminophen (Tylenol), but if the client's blood pressure is elevated, the Tylenol will not help. 4. The number 1 risk factor for a CVA is arterial hypertension. Because the client has a history of a CVA and is complaining of a severe headache, which is a symptom of hypertension, the nurse should first take the client's blood pressure. If it is elevated, the client needs to be taken to the emergency department. In the home setting, asking about the pain scale would not affect the care the nurse provides.

To which collaborative healthcare team member should the critical care nurse refer the client in the late stages of myasthenia gravis (MG)? 1. Occupational therapist. 2. Physical therapist. 3. Social worker. 4. Speech therapist.

Correct answer: 4 1. The occupational therapist addresses assisting the client with ADLs, but with MG the client will have no problems with ADLs if the client takes the medication correctly, 30 minutes prior to performing ADLs. 2. A physical therapist addresses transfer and movement issues with the client, but this would not be priority in the critical care unit. 3. The social worker assists the client with discharge issues or financial issues, but this would not be appropriate for the client in the critical care unit. 4. Speech therapists address swallowing problems, and clients with MG are dysphagic and are at risk for aspiration; the speech therapist can help match food consistency to the client's ability to swallow and thus help enhance client safety. This referral would be appropriate in the critical care unit.

The charge nurse has received laboratory data for clients in the medical department. Which client would require intervention by the charge nurse? 1. The client diagnosed with a stroke who has a platelet level of 250,000 μ/L. 2. The client with a seizure disorder who has a divalproex (Depakote) level of 75 μg/mL. 3. The client with multiple sclerosis on prednisone who has a glucose level of 208 mg/dL. 4. The client receiving the anticonvulsant phenytoin (Dilantin) who has serum levels of 24 mg/dL.

Correct answer: 4 1. The serum platelet level is within the normal range of 150,000 to 400,000 mL; therefore, this laboratory does not warrant intervention by the charge nurse. 2. A therapeutic Depakote level is 50 to 100 ug/ mL; therefore, this laboratory result does not warrant action by the nurse. 3. Steroids, such as prednisone, elevate a client's blood glucose level; therefore, this does not warrant intervention by the nurse. 4. The therapeutic range for Dilantin is 10-20 mg/dL. This client's higher level warrants intervention because the serum level is above therapeutic range.

The client on the rehabilitation unit post-motor vehicle accident has been prescribed 50 mg of Baclofen (Lioresol) per dose orally for muscle spasms. Baclofen comes in 10-mg, 20-mg, and 75-mg tablets. How many tablets should the nurse administer and in which quantity? _______ tablet(s)

Correct answer: Two 20-mg tablets and one 10-mg tablet 20 + 20 + 10 = 50 mg. The nurse cannot split a 75-mg tablet into 2/3 of a tablet, so the patient must receive multiple tablets.