Chapter 9 - Prioritization, Delegation, and Assignment Q&A 100% Verified 2023

The nurse is assessing a client with a neurologic health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's *best* action? •Perform a complete neurologic assessment •Assess the cranial nerve functions •Contact the Rapid Response Team •Reassess the client in 30 minutes - ANS-•Contact the Rapid Response Team •A change in level of consciousness and orientation is the earliest and most reliable indication that central neurologic function has declined. If a decline occurs, contact the Rapid Response Team or health care provider immediately. The nurse should also perform a focused assessment to determine if there are any other changes. The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which questions would the nurse use to determine orientation? *Select all that apply.* •When did you first experience the headache symptoms? •Who is the Mayor of Cleveland? •What is your health care provider's name? •What year and month is this? •What is your parents' address? •What is the name of this health care facility? - ANS-•When did you first experience the headache symptoms? •What is your health care provider's name? •What year and month is this? •What is the name of this health care facility? •After determining alertness in a client, the next step is to evaluate orientation. When the client's attention is engaged, ask him or her questions to determine orientation. Varying the sequence of questioning on repeated assessments prevents the client from memorizing the answers. Responses that indicate orientation include the ability to answer questions about person, place, and time by asking for information such as the client's ability to relate the onset of symptoms, the name of his or her health care provider or nurse, the year and month, his or her address, and the name of the referring physician or health care agency. Asking about mayors' names or parents' address may be inappropriate to assess orientation. What is the *priority* nursing concern for a client experiencing a migraine headache? •Pain •Anxiety •Hopelessness •Risk for brain injury - ANS-•Pain •The priority for interdisciplinary care for the client experiencing a migraine headache is pain management. All of the other problems are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating. The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? *Select all that apply.* •Foods that contain tyramine, such as alcohol and aged cheese, should be avoided •Drugs such as nitroglycerin and nifedipine should be avoided •Abortive therapy is aimed at eliminating the pain during the aura •A potential side effect of medications is rebound headache •Complementary therapies such as biofeedback and relaxation may be helpful •Estrogen therapy should be continued as prescribed by the client's health care provider - ANS-•Foods that contain tyramine, such as alcohol and aged cheese, should be avoided •Drugs such as nitroglycerin and nifedipine should be avoided •Abortive therapy is aimed at eliminating the pain during the aura •A potential side effect of medications is rebound headache •Complementary therapies such as biofeedback and relaxation may be helpful •Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate and should be included in the teaching plan. After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel (UAP)? •Documenting the seizure •Performing neurologic checks •Checking the client's vital signs •Restraining the client for protection - ANS-•Checking the client's vital signs •Measurement of vital signs is within the education and scope of practice of UAPs. The nurse should perform neurologic checks and document the seizure. Clients with seizures should not be restrained; however, the nurse may guide the client's movements if necessary to prevent injury. The nurse is preparing to admit a client with a seizure disorder. Which action can be assigned to an LPN/LVN? CONTINUES...