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Dif applyingapplication ref 831 key brain

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DIF:Applying/ApplicationREF:831KEY: Brain trauma/injury/tumorMSC: Integrated Process: Teaching/LearningNOT:Client Needs Category: Safe and Effective Care Environment: Safety and InfectionControl17.A nurse delegates care to the unlicensed assistive personnel (UAP). Which statement shouldthe nurse include when delegating care for a client with cranial nerve II impairment?a.“Tell the client where food items are on the breakfast tray.”b.“Place the client in a high-Fowler’s position for all meals.”c.“Make sure the client’s food is visually appetizing.”d.“Assist the client by placing the fork in the left hand.”ANS: ACranial nerve II, the optic nerve, provides central and peripheral vision. A client who hascranial nerve II impairment will not be able to see, so the UAP should tell the client wheredifferent food items are on the meal tray. The other options are not appropriate for a clientwith cranial nerve II impairment.DIF:Applying/ApplicationREF:835KEY:Brain trauma/injury/tumor| delegation| unlicensed assistive personnel (UAP)MSC: Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care18.A nurse prepares a client for lumbar puncture (LP). Which assessment finding should alertthe nurse to contact the health care provider?a.Shingles on the client’s backb.Client is claustrophobicc.Absence of intravenous accessd.Paroxysmal nocturnal dyspneaANS: A
An LP should not be performed if the client has a skin infection at or near the puncture sitebecause of the risk of infection. A nurse would want to notify the health care provider ifshingles were identified on the client’s back. If a client has shortness of breath when lyingflat, the LP can be adapted to meet the client’s needs. Claustrophobia, absence of IV access,and paroxysmal nocturnal dyspnea have no impact on whether an LP can be performed.DIF:Applying/ApplicationREF:849KEY: Assessment/diagnostic examination| interdisciplinary team| communicationMSC: Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care19.A nurse assesses a client who is recovering from a lumbar puncture (LP). Whichcomplication of this procedure should alert the nurse to urgently contact the health careprovider?a.Weak pedal pulsesb.Nausea and vomitingc.Increased thirstd.Hives on the chestANS: BThe nurse should immediately contact the provider if the client experiences a severeheadache, nausea, vomiting, photophobia, or a change in level of consciousness after an LP,which are all signs of increased intracranial pressure. Weak pedal pulses, increased thirst,and hives are not complications of an LP.DIF:Remembering/KnowledgeREF:831KEY: Assessment/diagnostic examination| interdisciplinary team| communicationMSC: Integrated Process: Communication and DocumentationNOT:Client Needs Category: Safe and Effective Care Environment: Management of Care20.A nurse cares for a client who is recovering from a single-photon emission computedtomography (SPECT) with a radiopharmaceutical agent. Which statement should the nurseinclude when discussing the plan of care with this client?

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Term
Fall
Professor
N/A
Tags
Test, The Grave, holistic client needs

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