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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.
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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.
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 plans care for a client with epilepsy. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
- A. Keep bed rails up at all times.
- B. Maintain the client on strict bedrest.
- C. Ensure that the client has IV access.
- D. Provide a high-protein diet.
- E. Keep oxygen and suction equipment available.
Correct Answer: A,C,E
Rationale: Oxygen and suctioning equipment with an airway must be readily available. Bed rails should be up at all times to prevent injury from a fall during a seizure. A saline lock provides venous access for IV drug therapy to manage seizures. Padded tongue blades are dangerous, dietary restrictions are not indicated, and strict bedrest is not necessary.
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.
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which a nurse should the nurse needs in this clients teaching?
- A. Take this drug only when you have prodforma symptoms indicating the onset of a migraine headache.
- B. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
- C. This drug will relieve the pain during the arm phase soon after a headache has started.
- D. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.
Correct Answer: B
Rationale: Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.