Nokea
A nurse is assessing a client who was brought into the emergency room following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?
- A. Administer an antipyretic
- B. Complete a vascular assessment
- C. Assess the cranial nerves
- D. Decrease environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Assess the cranial nerves. Meningococcal meningitis can affect the cranial nerves, leading to symptoms such as photophobia, altered mental status, and cranial nerve deficits. Assessing the cranial nerves will help the nurse to further evaluate the client's neurological status and identify any abnormalities that may indicate the severity of the condition. Administering an antipyretic (A) may help reduce fever but does not address the underlying issue. Completing a vascular assessment (B) is not a priority in this situation. Decreasing environmental stimuli (D) may be helpful for a seizure but is not the next priority after implementing droplet precautions.
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A nurse is caring for a client who has Parkinson's disease and is starting to display bradykinesia. Which of the following is an appropriate action by the nurse?
- A. Place the client on a low-protein, low-calorie diet
- B. Teach the client to walk more quickly when ambulating
- C. Complete passive range-of-motion exercises daily
- D. Give the patient extra time to perform activities
Correct Answer: D
Rationale: The correct answer is D: Give the patient extra time to perform activities. Bradykinesia is a common symptom of Parkinson's disease characterized by slow movement. By giving the patient extra time to perform activities, the nurse can accommodate the decreased speed of movement associated with bradykinesia, promoting independence and preventing frustration. Placing the client on a low-protein, low-calorie diet (A) is not relevant to addressing bradykinesia. Teaching the client to walk more quickly (B) may not be feasible due to the physical limitations caused by the condition. Completing passive range-of-motion exercises daily (C) may be beneficial for maintaining mobility but does not directly address bradykinesia. Giving the patient extra time to perform activities (D) is the most appropriate action as it supports the client's autonomy and helps manage the symptom effectively.
A nurse advises a client with osteoporosis to have three servings of milk or dairy products daily. Which of the following levels of prevention is being used by the nurse?
- A. Secondary prevention
- B. Primary prevention
- C. Proactive prevention
- D. Tertiary prevention
Correct Answer: B
Rationale: The correct answer is B: Primary prevention. This is because the nurse is promoting strategies to prevent osteoporosis from developing in the first place. By advising the client to have three servings of milk or dairy products daily, the nurse is focusing on educating and promoting healthy behaviors to reduce the risk of osteoporosis.
A: Secondary prevention involves early detection and treatment of a disease to prevent complications.
C: Proactive prevention is not a recognized term in public health and prevention frameworks.
D: Tertiary prevention focuses on managing and treating existing conditions to prevent further complications.
In summary, the nurse's advice falls under primary prevention as it aims to prevent the onset of osteoporosis through promoting healthy behaviors.
A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client's nutritional status?
- A. Restrict drinking fluids before and during meals
- B. Plan medication doses to occur before meals
- C. Increase the amount of fat and carbohydrates in meals
- D. Eat three large meals per day
Correct Answer: B
Rationale: The correct answer is B: Plan medication doses to occur before meals. This is because Myasthenia gravis can cause difficulty swallowing, leading to weight loss. Taking medication before meals can enhance the client's ability to eat by improving muscle strength for swallowing and chewing. Restricting fluids (A) may exacerbate swallowing difficulties. Increasing fat and carbohydrates (C) can lead to weight gain but may not address the swallowing issue. Eating three large meals (D) may be challenging for someone with swallowing difficulties.
A nursing preceptor is reviewing life expectancy in the twentieth century with a new nurse. The nurse should recognize that which of the following was most responsible for the dramatic increase in life expectancy during the twentieth century?
- A. Use of antibiotics to fight infections
- B. Sanitation and other public health activities
- C. Technology increases in the field of medical laboratory research
- D. Advances in surgical techniques and procedures
Correct Answer: B
Rationale: The correct answer is B: Sanitation and other public health activities. Improved sanitation, clean water supply, and public health initiatives such as vaccination programs played a crucial role in increasing life expectancy in the 20th century. Sanitation helped reduce the spread of infectious diseases, leading to a significant decrease in mortality rates. Public health activities focused on prevention rather than treatment, which had a long-term positive impact on overall population health. Antibiotics (choice A) were important but came later in the century. Technology increases in medical laboratory research (choice C) and advances in surgical techniques (choice D) contributed to healthcare improvements but were not the primary factors behind the dramatic increase in life expectancy.
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.