A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

A client who has a headache following a grade 1 concussion.

A client who has experienced brain death and is awaiting organ procurement.

A client who has a score of 10 on the Glasgow Coma Scale following a motor vehicle crash.

A client who has a score of 0 on the NIH Stroke Scale following a transient ischemic attack.

Answer and Explanation

The Correct Answer is C

Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.

Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.

Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.

Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.

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Correct Answer is A

Explanation

Choice A reason : Displaying a monthly calendar can help orient a client with Alzheimer's disease to the date and assist with maintaining a sense of time, which can be beneficial in managing cognitive impairment.

Choice B reason: Providing plenty of stimulation can be overwhelming for clients with Alzheimer's disease. A calm and predictable environment is usually more beneficial.

Choice C reason: Keeping the room dark at night can promote sleep, but it is not the only consideration. A nightlight or low-level lighting can prevent falls if the client needs to get up during the night.

Choice D reason: Providing structured activities can help fill the client's time and provide a sense of purpose, but it should be tailored to the individual's abilities and preferences.

A. The client moves the cane 2 feet ahead. B. The client holds the cane with their right hand. C. The client takes a step with their left foot first. D. The client advances the weaker (left) leg forward to the cane.

Correct Answer is D

Explanation

Choice A reason: Moving the cane 2 feet ahead is too far and can cause imbalance or a fall. The cane should be moved a short distance ahead, about the length of one natural step.

Choice B reason: Holding the cane with the right hand is correct for someone with left-sided weakness. The cane should be used on the stronger side of the body to provide support for the weaker side.

Choice C reason : Taking a step with the left foot first is not correct because the weaker leg should be advanced to the cane to ensure stability and support when moving.

Choice D reason: Advancing the weaker leg forward to the cane is correct. The cane provides support for the weaker leg, helping to maintain balance as the client walks.

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A charge nurse on a neurological unit is making room assignments for a group of clients. Which of the following clients should the nurse assign to the room closest to the nurses' station?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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