Nokea
A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid x 3 days, then 30 units IM bid x 3 days, then 20 units IM bid x 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include?
- A. Encouraging her to perform all care activities for herself
- B. Frequent ambulation to retain joint mobility
- C. Scheduling frequent rest periods between physical activity
- D. Feeding the client to reduce energy needs
Correct Answer: C
Rationale: Frequent rest periods are essential to manage fatigue, a common symptom in multiple sclerosis, while supporting activity as tolerated.
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The client with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.
The nurse is reviewing the medication list of the client with Meniere's disease. Which medication was likely prescribed for treating the client's vertigo?
- A. Meclizine
- B. Megestrol
- C. Meropenem
- D. Metoprolol
Correct Answer: A
Rationale: The anticholinergic and antihistamine properties of meclizine (Antivert) treat the symptom of vertigo. Megestrol, meropenem, and metoprolol treat unrelated conditions.
A stroke victim regains consciousness three days after admission. She has right-sided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following?
- A. Stay with her and give her time and encouragement in attempting to speak.
- B. Say, 'I'm sure you want a glass of water. I'll get it for you.'
- C. Say, 'Don't get upset. You rest now and I'll come back later and try to talk to you then.'
- D. Encourage her attempts and say, 'Don't worry, it will get easier every day.'
Correct Answer: A
Rationale: Staying with the client and offering encouragement supports her attempts to speak, fostering communication and emotional support.
The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?
- A. The client is ambulating without assistance.
- B. The client is sneezing with the mouth open.
- C. There is some slight serosanguineous drainage.
- D. The client reports hearing popping in the affected ear.
Correct Answer: A
Rationale: Ambulating without assistance post-stapedectomy risks vertigo and falls, requiring intervention. Open-mouth sneezing, slight drainage, and popping are expected.
A teenager is admitted following a seizure. The next day, the nurse goes into his room and finds him lying on the floor starting to have a seizure. What action should the nurse take at this time?
- A. Carefully observe the seizure and gently restrain him
- B. Attempt to put an airway in his mouth so he does not swallow his tongue, and observe the type and duration of the seizure
- C. Place something soft under his head, carefully observe the seizure, and protect him from injury
- D. Shout for help so that someone can help you move him away from the furniture
Correct Answer: C
Rationale: Placing something soft under the head and observing the seizure while protecting from injury ensures safety. Restraining or inserting an airway is not recommended, and the scenario does not indicate furniture-related danger.