Nokea
A nurse is planning discharge education for a patient who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?
- A. Care of the cervical collar
- B. Technique for performing neck ROM exercises
- C. Home assessment of ABGs
- D. Techniques for restoring nerve function
Correct Answer: A
Rationale: Cervical collar care is essential for post-diskectomy recovery to maintain alignment. ROM exercises, ABG assessment, and nerve restoration are not appropriate.
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A patient, brought to the clinic by his wife and son, is diagnosed with Huntington disease. When providing anticipatory guidance, the nurse should address the future possibility of what effect of Huntington disease?
- A. Metastasis
- B. Risk for stroke
- C. Emotional and personality changes
- D. Pathologic bone fractures
Correct Answer: C
Rationale: Huntington's disease causes significant emotional and personality changes due to neurologic degeneration. It is not malignant, nor does it increase stroke or fracture risk.
A patient with a brain tumor has begun to exhibit signs of cachexia. What subsequent assessment should the nurse prioritize?
- A. Assessment of peripheral nervous function
- B. Assessment of cranial nerve function
- C. Assessment of nutritional status
- D. Assessment of respiratory status
Correct Answer: C
Rationale: Cachexia involves weight loss and muscle atrophy, necessitating nutritional assessment to address deficits. Other assessments are less directly related.
A patient with suspected Parkinsons disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?
- A. When the patient is resting
- B. When the patient is ambulating
- C. When the patient is preparing his or her meal tray to eat
- D. When the patient is participating in occupational therapy
Correct Answer: A
Rationale: Parkinson's resting tremor is most evident when extremities are motionless, disappearing with purposeful movement. Assessment during rest is optimal.
A 25-year-old female patient with brain metastases is considering her life expectancy after her most recent meeting with her oncologist. Based on the fact that the patient is not receiving treatment for her brain metastases, what is the nurses most appropriate action?
- A. Promoting the patients functional status and ADLs
- B. Ensuring that the patient receives adequate palliative care
- C. Ensuring that the family does not tell the patient that her condition is terminal
- D. Promoting adherence to the prescribed medication regimen
Correct Answer: B
Rationale: Untreated brain metastases lead to a rapid decline, making palliative care the priority to manage symptoms and improve quality of life. Promoting function or withholding information is less appropriate.
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?
- A. Chronic confusion
- B. Impaired urinary elimination
- C. Impaired verbal communication
- D. Bowel incontinence
Correct Answer: C
Rationale: ALS causes progressive speech impairment, making impaired verbal communication a primary concern. Cognitive function, bladder, and bowel control are typically preserved.