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A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
- A. Photophobia
- B. Dilated pupils
- C. Headache
- D. Widened pulse pressure
- E. Bradycardia
Correct Answer: B,D,E
Rationale: Increased ICP in encephalitis is indicated by dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are symptoms of encephalitis but not specific to increased ICP.
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After teaching a client newly diagnosed with spieplety, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?
- A. I will drink more water daily to prevent my mouth from getting dry.
- B. This medication will stop me from getting an aura before a seizure.
- C. I will not drive a motor vehicle while taking this medication.
- D. Even when my seizure stop I will continue to take this drug.
Correct Answer: D
Rationale: Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
A nurse is teaching the daughter of a client who has Alzheimers disease. The daughter asks, Will the medication my mother is taking improve her dementia? How should the nurse respond?
- A. It will allow your mother to live independently for several more years.
- B. It is used to halt the advancement of Alzheimers disease but will not cure it.
- C. It will not improve her dementia but can help control emotional responses.
- D. It will cure the dementia but not improve memory.
Correct Answer: C
Rationale: Medications for Alzheimer's disease, such as cholinesterase inhibitors, do not improve dementia or halt its progression but can help manage symptoms, including emotional responses. The other options are incorrect as they overstate the medication's effects or are not accurate.
A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?
- A. Ambulate the client in the hallway twice a day.
- B. Teach the client pursed-lip breathing techniques.
- C. Keep the head of the bed at 30 degrees or greater.
- D. Provide small, frequent meals to prevent aspiration.
Correct Answer: C
Rationale: Elevation of the head of the bed will help prevent aspiration, a common risk in Parkinson disease due to swallowing difficulties. Ambulation in the hallway prevents venous thrombosis but does not address aspiration. Pursed-lip breathing is not relevant, and small, frequent meals are beneficial but not the primary intervention listed.
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
- A. Do you live in a crowded residence?
- B. When was your last tetatuss vaccination?
- C. Have you had any viral infections recently?
- D. Have you had any viral infections in the last month?
Correct Answer: A
Rationale: Living in a crowded residence increases the risk of bacterial meningitis due to close contact and potential spread of infection. Questions about tetanus vaccination or recent viral infections are less relevant to the focused history for bacterial meningitis.
A nurse is teaching a client who experiences migraine headaches. Which statement should the nurse include in the teaching to help prevent the onset of migraine headaches?
- A. Wear dark sunglasses when you are in brightly lit spaces.
- B. Lie down in a darkened room when you experience a headache.
- C. Set your alarm to ensure you do not sleep longer than 6 hours at one time.
- D. Take over-the-counter pain relievers as soon as the headache starts.
Correct Answer: B
Rationale: At the onset of a migraine attack, lying down in a darkened room can alleviate pain. The client may cover both eyes and use a cool cloth on the forehead. If the client falls asleep, they should remain undisturbed. The other options are not recognized therapies for migraines.