NUR402- Neuro

The nurse has just received the shift report. Which client should the nurse assess first?

Questions taken from: Hargrove-Huttel R.A &Colgrove, K.C. (2014). Prioritization, Delegation, & Management of Care for the NCLEX-RN Exam. F.A. Davis.

• The client with Guillain-Barré syndrome who has ascending paralysis to the knees.

• The client with a C-6 spinal cord injury who has autonomic dysreflexia

• The client with Parkinson’s disease who is experiencing “pill rolling.”

• The client with Huntington’s disease who has writhing, twisting movements of the face.

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?

• Perform a neurological assessment.

• Notify the client’s healthcare provider

• Ask the wife to explain more about the behavior

• Determine when the client last had something to eat.

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?

• “How does the client swallow the medications?”

• “Did you complete your head to toe assessment?”

• “Does the client have some Thick-It in the room?”

• “Why would you delegate feeding to a UAP?”

. 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?

• Have the staff nurse answer the telephone calls from clients

• Instruct the staff nurse to work in the radiology department

• Tell the staff nurse to work in the front desk triage area.

• Assign the staff nurse to work in the oncology clinic.

The terminally ill client [on palliative care] 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?

• Administer the narcotic pain medication IVP.

• Turn and reposition the client for comfort.

• Refuse to administer pain medication.

• Notify the HCP of the client’s vital signs.