Choice A reason: A Glasgow Coma Scale motor score of 5 indicates localized movement to pain, not an inability to move extremities. The client can move purposefully, ruling out complete paralysis. The total GCS score of 13 suggests mild impairment, not severe motor deficits, making this conclusion incorrect.

Choice B reason: A verbal score of 5 on the Glasgow Coma Scale indicates oriented speech, meaning the client can vocalize and respond appropriately. This contradicts the conclusion of being unable to make vocal sounds, as the score reflects intact verbal ability, not mutism or severe impairment.

Choice C reason: An eye-opening score of 3 indicates the client opens eyes to speech, not specifically when spoken to, as this could include spontaneous opening to sound. The conclusion is imprecise, and the total GCS score of 13 suggests mild impairment, not specific to this action.

Choice D reason: A total Glasgow Coma Scale score of 13 (3 for eye opening, 5 for verbal, 5 for motor) indicates mild traumatic brain injury, not unconsciousness. Unconsciousness typically corresponds to a GCS of 8 or less, with lower scores reflecting severe impairment, making this conclusion incorrect for this client.

Choice A reason: Kernig’s sign is a clinical indicator of meningitis, characterized by pain and resistance when extending the leg from a flexed position at the hip and knee. This occurs due to inflammation of the meninges, which causes irritation of the spinal nerve roots, leading to muscle stiffness and discomfort during leg extension, reflecting meningeal irritation.

Choice B reason: Brudzinski’s sign involves involuntary flexion of the hips and knees when the neck is flexed, indicating meningeal irritation in meningitis. It differs from Kernig’s sign, as it is elicited by neck movement rather than leg extension. While both signs suggest meningitis, Brudzinski’s sign is not observed in the described leg extension scenario.

Choice C reason: Nuchal rigidity refers to neck stiffness, a common meningitis symptom, where the client resists neck flexion due to meningeal inflammation. Unlike Kernig’s sign, it is not associated with leg movement. It reflects irritation of the meninges but is not the specific condition observed during the leg extension test described in the scenario.

Choice D reason: Bradykinesia, characterized by slow movement, is typically associated with neurological disorders like Parkinson’s disease, not meningitis. It involves impaired motor control due to basal ganglia dysfunction, unrelated to meningeal inflammation or leg extension pain. Therefore, it does not correspond to the clinical presentation described in the meningitis assessment scenario.

Choice A reason: Providing fluid hydration is not the primary purpose of an osmotic diuretic in this context. Osmotic diuretics, like mannitol, draw fluid from tissues into the bloodstream, reducing intracranial pressure by decreasing brain edema. Hydration may occur as a secondary effect, but it is not the goal in treating increased intracranial pressure.

Choice B reason: Osmotic diuretics, such as mannitol, reduce brain edema by creating an osmotic gradient that pulls fluid from swollen brain tissue into the bloodstream, lowering intracranial pressure. This alleviates pressure on brain structures, preventing complications like herniation, making it the primary purpose of the medication in this clinical scenario.

Choice C reason: Increasing cell size in the brain is not the purpose of osmotic diuretics. These medications reduce brain cell swelling by drawing water out of cells into the vascular compartment. Enlarging brain cells would exacerbate intracranial pressure, counteracting the therapeutic goal of managing cerebral edema in this condition.

Choice D reason: Expanding extracellular fluid volume is not the primary goal of osmotic diuretics in this context. While they increase blood volume temporarily by drawing fluid from tissues, the aim is to reduce brain edema and intracranial pressure, not to expand extracellular fluid, which could worsen pressure dynamics in the brain.

Choice A reason: Discontinuing intravenous access is inappropriate for a STEMI client, as IV access is critical for administering medications like anticoagulants, antiplatelets, and thrombolytics, or for emergency interventions. Maintaining IV access supports rapid treatment to restore coronary blood flow, which is essential in managing acute myocardial infarction effectively.

Choice B reason: A non-contrast CT scan is not typically indicated for STEMI management. STEMI is diagnosed via EKG and requires urgent revascularization, often through cardiac catheterization. CT scans may be used for other conditions, like stroke, but they do not address the urgent need to restore coronary artery perfusion in STEMI.

Choice C reason: Holding anticoagulant therapies is contraindicated in STEMI, as these medications (e.g., heparin) prevent further clot formation and stabilize the existing thrombus. Anticoagulants are critical in conjunction with revascularization procedures like cardiac catheterization to improve blood flow and reduce myocardial damage in acute infarction.

Choice D reason: Cardiac catheterization is the standard intervention for STEMI, allowing visualization and treatment of coronary artery blockages via percutaneous coronary intervention (PCI). It restores blood flow to the ischemic myocardium, minimizing tissue damage. The nurse anticipates this procedure as it directly addresses the underlying cause of STEMI, a blocked coronary artery.

Choice A reason: Placing the client with the head reclined back is unsafe for dysphagia, as it increases aspiration risk by allowing food or liquid to enter the airway. Proper positioning involves an upright posture (90 degrees) to facilitate safe swallowing by aligning the esophagus and reducing the chance of aspiration.

Choice B reason: Encouraging brief exercise before meals may promote appetite but is not directly related to feeding safety in dysphagia. The priority is preventing aspiration and ensuring safe swallowing, which involves techniques like upright positioning and small bites, rather than focusing on appetite stimulation in this context.

Choice C reason: Encouraging small bites is a critical safety measure for dysphagia. Smaller food volumes reduce the risk of choking and aspiration by allowing better control during swallowing. This technique helps compensate for impaired pharyngeal muscle coordination post-stroke, ensuring safer food passage into the esophagus.

Choice D reason: Placing food on the affected side of the mouth is incorrect for dysphagia management. Food should be placed on the unaffected side to leverage stronger muscle control for swallowing. The affected side may have impaired sensation or motor function, increasing aspiration risk if food is placed there.

Choice A reason: Administering a nitrate antihypertensive is not the first action for autonomic dysreflexia. While it may help manage hypertension, the priority is identifying and removing the triggering stimulus, such as bladder distention, which causes the autonomic response. Addressing the cause prevents further escalation of the life-threatening hypertensive crisis.

Choice B reason: Obtaining the client’s heart rate provides additional data but is not the priority. Autonomic dysreflexia is characterized by severe hypertension due to a noxious stimulus below the spinal injury level. Checking for triggers like bladder distention is critical first to eliminate the cause and stabilize blood pressure.

Choice C reason: Placing the client in a high-Fowler’s position may help manage hypertension by reducing preload, but it is not the first action. Autonomic dysreflexia requires identifying and removing the trigger, such as bladder distention, to prevent ongoing sympathetic overactivity, which drives the hypertensive crisis in spinal cord injury clients.

Choice D reason: Checking for bladder distention is the first action, as it is a common trigger of autonomic dysreflexia in quadriplegia. A distended bladder causes a noxious stimulus, triggering an exaggerated sympathetic response, leading to severe hypertension. Relieving the distention (e.g., via catheterization) addresses the root cause, stabilizing the client’s condition.

Choice A reason: Measuring vital signs every 6 hours is insufficient for post-cardiac catheterization monitoring. Vital signs should be checked more frequently (e.g., every 15–30 minutes initially) to detect complications like bleeding or hemodynamic instability. Less frequent monitoring fails to ensure timely identification of issues at the femoral access site.

Choice B reason: Sitting the client upright immediately after the procedure is contraindicated. Post-femoral catheterization, clients must remain flat with the leg extended to prevent bleeding or hematoma at the puncture site. Early upright positioning increases pressure on the femoral artery, risking vascular complications and disrupting clot formation.

Choice C reason: Keeping the hip and leg extended straight is essential to prevent flexion at the femoral puncture site, reducing the risk of bleeding or hematoma formation. Maintaining this position stabilizes the access site, promotes clot formation, and minimizes vascular complications following catheter removal in the left femoral vessel.

Choice D reason: Checking all pulses in the left lower extremity is critical to assess for vascular complications, such as arterial occlusion or thrombosis, post-catheterization. Comparing distal pulses (e.g., dorsalis pedis, posterior tibial) to baseline ensures adequate blood flow and detects early signs of compromised circulation in the affected limb.

Choice E reason: Bedrest for up to 6 hours, as prescribed, is necessary to minimize movement and pressure on the femoral puncture site, preventing bleeding or hematoma. This duration allows sufficient time for clot stabilization at the access site, reducing the risk of vascular complications while promoting safe recovery.

Choice A reason: Disorientation is a hallmark of increased intracranial pressure in hydrocephalus, as excess cerebrospinal fluid compresses brain tissue, impairing cognitive function. This pressure disrupts neural pathways in the cerebral cortex, leading to confusion and altered mental status, signaling worsening intracranial dynamics that require urgent intervention.

Choice B reason: Anuria, or absent urine output, is not typically associated with increased intracranial pressure in hydrocephalus. It may indicate renal dysfunction or systemic issues but does not directly result from brain compression or cerebrospinal fluid accumulation, making it an unlikely indicator of worsening ICP in this context.

Choice C reason: Neck pain and stiffness are more characteristic of meningitis than hydrocephalus-related increased ICP. While discomfort may occur, it is not a primary sign of ICP elevation. Increased pressure primarily affects brain function, causing neurological symptoms like disorientation or pupillary changes rather than localized neck symptoms.

Choice D reason: Pupillary changes, such as dilation or unequal pupils, indicate increased intracranial pressure in hydrocephalus. Compression of the oculomotor nerve (cranial nerve III) by elevated pressure disrupts pupil reactivity and size, signaling significant brain tissue displacement or herniation, necessitating immediate medical attention.

Choice E reason: Headache is a common symptom of increased intracranial pressure in hydrocephalus, resulting from cerebrospinal fluid accumulation stretching pain-sensitive structures like the meninges. The pressure increase causes diffuse or localized pain, often worsening with position changes, serving as a key indicator of escalating intracranial pressure.

Choice A reason: Cardiac enzymes, such as troponin, do not diagnose pulmonary congestion, which is assessed via imaging or clinical signs like crackles. These enzymes (troponin, CK-MB) are released from damaged myocardial cells during an MI, indicating heart tissue injury rather than lung-related conditions like congestion.

Choice B reason: Cardiac enzymes do not assess heart structure or valve mobility, which are evaluated using imaging techniques like echocardiography. Enzymes like troponin and CK-MB are specific to myocardial damage, rising in the blood post-MI to indicate the extent of heart tissue injury, not structural details.

Choice C reason: Cardiac enzyme tests, particularly troponin and CK-MB, measure the degree of myocardial damage after an MI. These proteins are released into the bloodstream when heart muscle cells die, with elevated levels correlating to the extent of tissue injury, aiding in assessing MI severity.

Choice D reason: Cardiac enzymes do not pinpoint the exact location of an MI. Localization is achieved through EKG changes or imaging like cardiac catheterization. Enzymes indicate the presence and extent of myocardial damage but lack specificity for identifying which coronary artery or heart region is affected.

Choice A reason: Wearing sunglasses is not an appropriate intervention for homonymous hemianopia, a visual field defect from stroke affecting the same side of both eyes. Sunglasses may reduce glare but do not address the loss of left visual field or help compensate for the neurological deficit.

Choice B reason: Scanning from left to right is incorrect for left homonymous hemianopia. This would prioritize the intact right visual field, neglecting the affected left side. Clients need to scan toward the affected side (right to left) to compensate for the visual loss and ensure awareness of their environment.

Choice C reason: Applying eye ointment is irrelevant for homonymous hemianopia, which results from brain damage (e.g., occipital lobe stroke) rather than ocular issues. Ointment may treat dry eyes or infections but does not address the neurological visual field defect caused by disrupted visual pathways.

Choice D reason: Teaching the client to scan from right to left is appropriate for left homonymous hemianopia. This compensates for the lost left visual field by training the client to actively turn their head toward the affected side, improving awareness of their environment and reducing collision risks.