Nokea
A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing 'strange things.' The nurse reassures the wife that the following behavior is normal with Parkinson's disease:
- A. Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.'
- B. Your husband may move his hands in motions that look like he is rolling a pill between his fingers.'
- C. Twitching of the muscles is to be expected and can occur at any time during the day.'
- D. Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times.'
Correct Answer: B
Rationale: Clients with Parkinson's disease generally experience stiffness and rigid movement. Pill-rolling movements are a symptom experienced by the Parkinson client. Twitching of the muscles is not an expected symptom of Parkinson's disease. Parkinson's disease does not cause joint pain. Mild muscular pain may be present.
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A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to:
- A. Request that he explain to the group why he took personal items from peers
- B. Approach him when he is alone to inquire about his involvement in the incident
- C. Imply to him that you doubt his involvement in the incident and request his denial
- D. Confront him openly in group and request an apology
Correct Answer: B
Rationale: This answer is incorrect. There is no proof that he removed the missing items. This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
Which diet selection by a client with a decubitus ulcer would indicate a clear understanding of the proper diet for healing of the ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of iced tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing decubitus ulcers requires a diet high in protein, vitamins (especially C and A), and zinc. Baked chicken breast (protein), broccoli (vitamin C), wheat roll (carbohydrates), and an orange (vitamin C) provide these nutrients. Options A, B, and D lack sufficient protein or include less nutrient-dense foods (e.g., caramel cake, French fries).
The client with cancer refuses to care for herself. Which action by the nurse would be best?
- A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client.
- B. Talk to the client and explain the need for self-care.
- C. Explore the reason for the lack of motivation seen in the client.
- D. Talk to the physician about the client's lack of motivation.
Correct Answer: C
Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.
Discharge teaching for the client who has a total gastrectomy should include which of the following?
- A. Need for the client to increase fluid intake to 3000 mL/day
- B. Follow-up visits every 3 weeks for the first 6 months
- C. B12 injections needed for the rest of the client's life
- D. Need to eat three full meals with plenty of fiber per day
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.
A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:
- A. Increased levels of the coagulation factors and a decrease in fibrinolysis
- B. An inadequate production of platelets
- C. An inadequate intake of folic acid during pregnancy
- D. An increase in fibrinolysis and a decrease in coagulation factors
Correct Answer: A
Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.