Nokea
A nurse witnesses a client with late-stage Alchimers disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?
- A. I see you are hungry; let's get you some toast.
- B. You ate your breakfast 30 minutes ago.
- C. It appears you are confused this morning.
- D. Your family will be here soon. Lets get you dressed.
Correct Answer: A
Rationale: Use of validation therapy with clients who have Alzheimer's disease involves acknowledging the client's feelings and concerns. This technique is more effective in later stages of the disease, as reality orientation may increase agitation. Offering toast validates the client's expressed hunger without confrontation.
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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 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 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 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.
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.