Nokea
A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this clients plan of care?
- A. Ambulate the client in the hallway twice a day.
- B. Teach the client pursed-lip breathing techniques.
- C. Keep the head of the bed at 30 degrees or greater.
- D. Provide small, frequent meals to prevent aspiration.
Correct Answer: C
Rationale: Elevation of the head of the bed will help prevent aspiration, a common risk in Parkinson disease due to swallowing difficulties. Ambulation in the hallway prevents venous thrombosis but does not address aspiration. Pursed-lip breathing is not relevant, and small, frequent meals are beneficial but not the primary intervention listed.
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A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
- A. Bleeding
- B. Hoarseness
- C. Dyspnea
- D. Dysphagia
- E. Seizures
Correct Answer: B,C,D
Rationale: Common complications of vagal nerve stimulation device implantation include hoarseness (most common), dyspnea, neck pain, and dysphagia. Bleeding is not a common complication, and seizures are not typically a post-procedure complication.
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 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 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.