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A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
- A. Bleeding
- B. Hoarseness
- C. Dyspnea
- D. Dysphagia
- E. Seizures
Correct Answer: B,C,D
Rationale: Common complications of vagal nerve stimulation device implantation include hoarseness (most common), dyspnea, neck pain, and dysphagia. Bleeding is not a common complication, and seizures are not typically a post-procedure complication.
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A nurse plans care for a client with epilepsy. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
- A. Keep bed rails up at all times.
- B. Maintain the client on strict bedrest.
- C. Ensure that the client has IV access.
- D. Provide a high-protein diet.
- E. Keep oxygen and suction equipment available.
Correct Answer: A,C,E
Rationale: Oxygen and suctioning equipment with an airway must be readily available. Bed rails should be up at all times to prevent injury from a fall during a seizure. A saline lock provides venous access for IV drug therapy to manage seizures. Padded tongue blades are dangerous, dietary restrictions are not indicated, and strict bedrest is not necessary.
A nurse cares for a client with advanced Alchimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
- A. This is a sign of fatigue. The client would benefit from a daily nap.
- B. Engage the client in scheduled activities throughout the day.
- C. It sounds like this is difficult for you. I will consult the social worker.
- D. The provider can prescribe a mild sedative for restlessness.
Correct Answer: B
Rationale: Several strategies may be used to cope with restlessness and wandering in Alzheimer's disease. Engaging the client in structured activities throughout the day is effective. Daily naps and sedatives are less effective, and consulting a social worker does not directly address the behavior.
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 assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
- A. Ipsilateral tearing
- B. Miosis
- C. Rhinorrhea
- D. Neck and shoulder tenderness
- E. Eyelid edema
Correct Answer: A,B,E
Rationale: Cluster headache is usually accompanied by ipsilateral tearing, miosis, rhinorrhea or nasal congestion, ptosis, eyelid edema, and facial sweating. Abrupt loss of consciousness, neck and shoulder tenderness, and exophthalmos are not associated with cluster headaches.
A nurse prepares to discharge a client with Alzheimer's disease. Which statement should the nurse include in the discharge teaching for this clients caregiver?
- A. Allow the client to rest most of the day.
- B. Place a padded throw rug at the bedside.
- C. Install deadbolt locks on all outside doors.
- D. Provide a high-calorie and high-protein diet.
Correct Answer: C
Rationale: Clients with Alzheimer's disease tend to wander, especially at night. Installing deadbolt locks on all outside doors prevents the client from going outdoors unsupervised, enhancing safety. The other options do not address wandering directly.