Nokea
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?
- A. Assist the client with frequent and meticulous oral care.
- B. Assess the clients ability to eat and swallow before each meal.
- C. Schedule appointments early in the morning to ensure rest in the afternoon.
- D. Monitor the client's blood pressure every hour.
Correct Answer: A
Rationale: Frequent and meticulous oral care is important for clients with Parkinson disease due to swallowing difficulties and drooling, which increase the risk of oral complications. Assessing swallowing is a nursing responsibility, not suitable for UAP delegation. Scheduling appointments and frequent blood pressure monitoring are not specific to Parkinson disease care.
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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.
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
- A. Sodium levels
- B. Clotting factors
- C. White blood cell count
- D. C-reactive protein
- E. Liver enzymes
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.
A nurse assesses a client after administering prescribed levetrincatam (Kepprna). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?
- A. Serum electrolyte levels
- B. Kidney function tests
- C. Complete blood cell count
- D. Liver function tests
Correct Answer: B
Rationale: Adverse effects of levetiracetam (Keppra) include coordination problems and renal toxicity. Kidney function tests should be monitored to detect potential adverse effects. The other laboratory tests are not typically affected by levetiracetam.
A nurse assesses a client who is at risk for secondary seizures. Which conditions place the client at risk? (Select all that apply.)
- A. Brain lesion from a tumor
- B. Metabolic disorder
- C. Acute alcohol withdrawal
- D. History of stroke
- E. Multiple sclerosis
Correct Answer: A,B,C,D
Rationale: Clients at risk for secondary seizures include those with brain lesions from tumors or trauma, metabolic disorders, acute alcohol withdrawal, electrolyte disturbances, high fever, stroke, or substance abuse. Multiple sclerosis and chronic pulmonary disease are not typically associated with secondary seizures.
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.