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A nurse cares for a client who is experiencing deteriorating neurologic function. The client states, 'I am worried I will not be able to care for my young children.' How should the nurse respond?
- A. Caring for your children is a priority. You may not want to ask for help, but you have to.
- B. Our community has resources that may help you with household tasks so you have energy to care for your children.
- C. You seem distressed. Would you like to talk to a psychologist about adjusting to your changing status?
- D. Give me more information about what worries you, so we can see if we can do something to make adjustments.
Correct Answer: D
Rationale: Exploring the client's specific concerns allows the nurse to tailor interventions and provide appropriate support. The other options make assumptions or suggest solutions without fully understanding the client's needs.
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A nurse assesses a client and notes the client's position as indicated in the illustration below: How should the nurse document this finding?
- A. Decorticate posturing
- B. Decerebrate posturing
- C. Flaccid posturing
- D. Spinal cord degeneration
Correct Answer: A
Rationale: Decorticate posturing indicates corticospinal pathway interruption, a serious finding requiring immediate documentation and reporting. The other options do not accurately describe this abnormal posture.
A nurse prepares to teach a client who has experienced damage to the left temporal lobe of the brain. Which action should the nurse perform when educating this client about newly prescribed medications?
- A. Help the client identify each medication by its color.
- B. Provide written materials with large print size.
- C. Sit on the client's right side and speak into the right ear.
- D. Allow the client to use a white board to ask questions.
Correct Answer: C
Rationale: The temporal lobe contains the auditory center for sound interpretation. The client's hearing will be impaired in the left ear. The nurse should sit on the client's right side and speak into the right ear to compensate for the hearing impairment caused by left temporal lobe damage. The other interventions do not directly address the hearing deficit associated with this condition.
A nurse assesses a client who demonstrates a positive Romberg's sign with eyes closed but not with eyes open. Which condition is most likely?
- A. Difficulty with proprioception
- B. Peripheral motor disorder
- C. Impaired cerebral function
- D. Positive pronator drift
Correct Answer: A
Rationale: A positive Romberg's sign with eyes closed but not with eyes open indicates difficulty with proprioception, as the client relies on vision to compensate for impaired position sense. The other options do not specifically describe this clinical finding.
A nurse assesses a client's recent memory. Which client statement confirms that the client's recent memory is intact?
- A. A young girl wrapped in a shroud fell asleep on a bed of clouds.
- B. I was born on April 3, 1967, in Johnstown Community Hospital.
- C. Apple, chair, and pencil are the words you just stated.
- D. I ate oatmeal with wheat toast and orange juice for breakfast.
Correct Answer: D
Rationale: Asking clients about recent events that can be verified, such as what they ate for breakfast, assesses recent memory. The other options assess different cognitive functions: making up a rhyme tests higher cognition, recalling birth details tests remote memory, and repeating words tests immediate memory.
A nurse performs an assessment of pain discrimination on an older adult client. The client correctly identifies, with eyes closed, a sharp sensation on the right hand when touched with a pin. Which action should the nurse take next?
- A. Touch the pin on the same area of the left hand.
- B. Contact the provider with the assessment results.
- C. Document the findings and end the assessment.
- D. Continue the assessment on the client's feet.
Correct Answer: A
Rationale: After confirming normal pain sensation on the right hand, the nurse should assess the left hand to ensure bilateral symmetry before moving to other areas like the feet. The finding is normal and does not require immediate reporting.