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 B

Explanation

Choice A reason : Desmopressin is a medication used to treat conditions like diabetes insipidus and certain cases of hemophilia, not allergic reactions such as hives and urticaria.

Choice B reason: Diphenhydramine is an antihistamine that is commonly used to treat allergic reactions, including hives and urticaria. It works by blocking the action of histamine, a substance in the body that causes allergic symptoms.

Choice C reason: Spironolactone is a diuretic and is not used to treat allergic reactions. It is typically prescribed for conditions like heart failure, hypertension, and certain hormonal disorders.

Choice D reason: Metoclopramide is a medication used to treat nausea and gastroparesis, not allergic reactions.

A. Turn the CPM machine off while the client is eating. B. Store the CPM machine on the floor when not in use. C. Check the settings of the CPM machine every 12 hours. D. Increase the range of motion rapidly when the CPM machine is used intermittently.

Correct Answer is A

Explanation

Choice A reason: This response is appropriate because it encourages the client to seek professional medical advice, ensuring they receive personalized recommendations based on their health status and needs. It also emphasizes the importance of a physical examination to rule out any contraindications or underlying health issues before starting any contraceptive method.

Choice B reason: Storing the CPM machine on the floor when not in use is not recommended as it can pose a tripping hazard and may not comply with safety standards. The machine should be stored properly according to the manufacturer's instructions to ensure safety and maintain the equipment's integrity.

Choice C reason:While barrier methods are a good option for preventing both pregnancy and sexually transmitted infections (STIs), suggesting a specific method without a full assessment of the client's needs and preferences is not ideal. It is better to involve a healthcare provider in the decision-making process.

Choice D reason: Increasing the range of motion rapidly when the CPM machine is used intermittently is not advised. Adjustments to the range of motion should be made gradually and according to the client's tolerance and the surgeon's orders. Rapid increases can cause pain and may hinder the healing process.

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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?

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