Nokea
A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?
- A. Establish the ability to communicate effectively.
- B. Increase mobility to a normal level.
- C. Promote independent living without assistance.
- D. Restore full visual function.
Correct Answer: A
Rationale: The correct answer is A: Establish the ability to communicate effectively. For a client who had a left hemispheric CVA, the left hemisphere is responsible for language and speech functions. Therefore, focusing on establishing effective communication is crucial in the rehabilitation program. It targets the specific deficits caused by the CVA and aims to improve the client's quality of life. Increasing mobility to a normal level (B) is important but may not be the priority in this case. Promoting independent living without assistance (C) is a broad goal that may encompass various aspects beyond communication. Restoring full visual function (D) is not directly related to a left hemispheric CVA.
You may also like to solve these questions
A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?
- A. pH below 7.35
- B. pH above 7.45
- C. HCO3- above 28 mEq/L
- D. PaCO2 above 45 mm Hg
Correct Answer: A
Rationale: The correct answer is A: pH below 7.35. In metabolic acidosis, there is a decrease in pH due to an excess of acid or a loss of bicarbonate ions. A pH below 7.35 indicates acidosis. Choices B and C are incorrect because in metabolic acidosis, the pH is below the normal range of 7.35-7.45, and the bicarbonate (HCO3-) level is typically below 24 mEq/L rather than above 28 mEq/L. Choice D is incorrect as an elevated PaCO2 (respiratory acidosis) is not typically seen in metabolic acidosis.
A nurse in an emergency department is caring for a client who reports substernal chest pain and dyspnea. The client is vomiting and is diaphoretic. Which of the following laboratory tests are used to diagnose a myocardial infarction? (Select all that apply.)
- A. Troponin I, Troponin T, CPK, Myoglobin
- B. Plasma low-density lipoproteins
- C. White blood cell count
- D. Blood glucose level
Correct Answer: A
Rationale: The correct answer is A. Troponin I, Troponin T, CPK, and Myoglobin are all specific laboratory tests used to diagnose a myocardial infarction. Troponin I and T are cardiac biomarkers released into the bloodstream following myocardial cell injury. Creatine phosphokinase (CPK) is an enzyme found in high concentrations in the heart muscle, and elevated levels indicate myocardial damage. Myoglobin is a protein released from damaged muscle cells, including cardiac muscle. These tests provide crucial information to confirm the diagnosis of a myocardial infarction.
Plasma low-density lipoproteins are not specific for diagnosing a myocardial infarction. White blood cell count is not typically used for diagnosing a myocardial infarction, although it may be elevated in response to inflammation associated with heart damage. Blood glucose level is not specific for diagnosing a myocardial infarction and
A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?
- A. Excessive thrombosis and bleeding
- B. Clotting of the mucous membranes
- C. Increase in platelet count
- D. Excessive red blood cell count
Correct Answer: A
Rationale: The correct answer is A: Excessive thrombosis and bleeding. In DIC, there is a widespread activation of the clotting cascade leading to formation of microthrombi, causing excessive clotting. However, as the clotting factors are depleted, bleeding can occur. This results in a paradoxical situation of both thrombosis and bleeding. B is incorrect as clotting of mucous membranes is not specific to DIC. C is incorrect as platelet count is usually decreased in DIC due to consumption. D is incorrect as excessive red blood cell count is not a characteristic of DIC.
A nurse is assessing a client before a packed RBC transfusion. What data is most important to obtain?
- A. Blood pressure
- B. Temperature
- C. Respiratory rate
- D. Oxygen saturation
Correct Answer: B
Rationale: The correct answer is B: Temperature. Before a packed RBC transfusion, it is crucial to assess the client's temperature as hyperthermia can indicate a possible transfusion reaction. Monitoring temperature helps in early detection and intervention. Blood pressure (A) is important but not the most crucial in this context. Respiratory rate (C) and oxygen saturation (D) are relevant but may not indicate an immediate issue with the transfusion. Other choices are not provided.
A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. White coating in the mouth
- B. Increased heart rate
- C. Insomnia
- D. Shortness of breath
Correct Answer: A
Rationale: The correct answer is A: White coating in the mouth. This adverse effect can indicate oral thrush, a fungal infection common with inhaled corticosteroids like fluticasone. The nurse should instruct the client to report this to the provider promptly for appropriate treatment. Increased heart rate (B) and insomnia (C) are common side effects of the medication but not usually serious enough to report immediately. Shortness of breath (D) is a symptom of poorly controlled asthma and should be addressed promptly but not considered an adverse effect of the medication in this context.