Reduction of Risk-Sensory-Perception-Mobility
1.
For a client with a neurological disorder, which nursing assessment will be most helpful in determining subtlechanges in the clients level of consciousness?a.
Client posturingb.
Glasgow Coma Scalec.
Client thinking patternd.
Occurrence of hallucinations
The Glasgow Coma Coma Scale score best evaluates changes in a clients level of consciousness by evaluating eyeopening, motor, and verbal responses. Option #1 indicates increased intracranial pressure. Options #3 and #4 aremore appropriate for the psychiatric client.
2.
The most important information for the nurse to obtain prior to a computerized axial tomography (CAT) scanconcerns:a.
problems being in closed spaces.b.
allergies to aspirin.c.
intact swallow and gag reflex.d.
full range of motion of all extremities.
If the client has claustrophobia, the scan may cause severe anxiety. Option #2 is incorrect because aspirin is not usedfor the scan. Options #3 and #4 are assessment data related to CVA but not necessary for CT scan.
3.
Which clients pain should be assessed initially?a.
A client experiencing pain 2 hours after a liver biopsy.b.
A client with a long leg cast who was medicated for pain 45 min. earlier.c.
A maternity client who experiences pain during breast feeding.d.
A 4-year-old child who complains of a sore throat after a tonsillectomy.
While it is important to evaluate any client's discomfort, this client could be developing compartmental syndrome andneeds immediate attention. It is important to further evaluate the pulse, sensation, movement, color, andtemperature. Options #1, #3, and #4 are not a priority to #2. A client will experience discomfort after a liver biopsy.There is a release of oxytocin during breast feeding which will cause some discomfort.
4.
Which nursing response indicates an understanding of a toddler that is drowsy after a grandmal seizure?a.
This is an expected finding after a seizure. Maintain bedrest and neurological assessments.b.
This indicates cortical damage. Assess for impaired motor and sensory function.c.
Another seizure will shortly occur. Precautions should be taken.d.
There is decreased sensory stimulation. Ambulate the child to initiate an increased response.
The postictal state sometimes leaves a client unresponsive, drowsy, and difficult to arouse. Options #2 and #3 are notcorrect. Option #4 is incorrect because an individual needs to rest after a seizure of this type.
5.
At the time of diagnosis, a client with Bell's Palsy is given a supply of eye patches. The client should be cautionedagainst:a.
allowing the cornea of the eye to become dry.b.
photosensitivity regarding light on the retina.c.
sudden movement of the head when bending over.d.
contamination from the affected eye to the other eye.
Paralysis of the eyelid allows the cornea to dry. Patches can be used to keep the eyelid closed to prevent damage.Drops and/or ointments are also used to reduce the chance of corneal damage. Option #2 is incorrect because theproblem, properly managed, should not result in a problem with light. Option #3 is for clients with increasedintraocular pressure. Option #4 is incorrect because Bells Palsy is not contagious.
6.
Which action should the nurse take if a CBC of a client receiving Cephalexin (Keflex) intravenously reflects asignificant decrease in red cells and platelets?a.
Withhold drug pending notification of physician regarding lab results.b.
Administer medication for next 2 scheduled doses and notify physician of CBC changes.c.
Discontinue drug until another CBC can be performed.d.
Proceed with administration of dose without delay.
Cephalexin is an antibiotic associated with the development of aplastic anemia. The physician should be notified assoon as the problem is identified. Options #2, #3, and #4 are not appropriate nursing decisions regarding thismedication.
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