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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.
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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.
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 an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Lip smacking
- B. Sudden loss of muscle tone
- C. Brief jerking of the extremities
- D. Picking at clothing
- E. Staring spell
Correct Answer: A,D,E
Rationale: Absence seizures are characterized by brief lapses in attention, often with staring spells, lip smacking, or picking at clothing. Sudden loss of muscle tone is more typical of atonic seizures, and brief jerking of extremities is associated with myoclonic seizures.
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 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.