Nokea
A family member brings the client to the emergency department reporting that the 78-year-old father has suddenly become very confused and thinks he is living in 1942, that he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member?
- A. Has your father been diagnosed with dementia?'
- B. What medication has your father taken today?'
- C. What have you given him that makes him think it's poison?'
- D. Does your father like to watch old movies on television?'
Correct Answer: B
Rationale: Sudden confusion and delusions suggest delirium, often medication-related. Asking about medications (B) identifies potential causes. Dementia (A) causes gradual decline, blaming poison (C) is untherapeutic, and movies (D) are irrelevant.
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The client is diagnosed with ALS. Which client problem would be most appropriate for this client?
- A. Disuse syndrome.
- B. Altered body image.
- C. Fluid and electrolyte imbalance.
- D. Alteration in pain.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness, leading to disuse syndrome (A) from immobility. Body image (B) is secondary, fluid/electrolyte issues (C) are not primary, and pain (D) is less common.
When preparing the client for an EEG, which nursing action is most appropriate?
- A. Administer a sedative 1 hour before the test.
- B. Withhold food and water after midnight on the day of the test.
- C. Assist with shampooing the client's hair.
- D. Take the client's blood pressure while lying and sitting.
Correct Answer: C
Rationale: Shampooing the client's hair ensures a clean scalp, improving electrode contact for an accurate EEG.
Which intervention is most appropriate for a client with Bell's palsy experiencing eye dryness?
- A. Apply warm compresses to the affected eye.
- B. Administer oral antihistamines.
- C. Use artificial tears as prescribed.
- D. Cover the unaffected eye with a patch.
Correct Answer: C
Rationale: Artificial tears prevent corneal damage from eye dryness in Bell's palsy due to incomplete eye closure.
The nurse is planning the care for a client diagnosed with Parkinson’s disease. Which would be a therapeutic goal of treatment for the disease process?
- A. The client will experience periods of akinesia throughout the day.
- B. The client will take the prescribed medications correctly.
- C. The client will be able to enjoy a family outing with the spouse.
- D. The client will be able to carry out activities of daily living.
Correct Answer: D
Rationale: A therapeutic goal for Parkinson’s disease is to maximize functional ability, such as carrying out ADLs (D). Akinesia (A) is a symptom to minimize, medication adherence (B) is a means to the goal, and family outings (C) are less specific.
In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?
- A. No reflex activity below the waist.
- B. Inability to move upper extremities.
- C. Complaints of a pounding headache.
- D. Hypotension and bradycardia.
Correct Answer: D
Rationale: Neurogenic shock in thoracic SCI results from loss of sympathetic tone, leading to hypotension and bradycardia (D). No reflex activity (A) indicates spinal shock, upper extremity paralysis (B) occurs in cervical SCI, and headache (C) is unrelated.