Nokea
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.
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An older adult has encouraged her husband to visit their primary care provider, stating that she is concerned that he may have Parkinsons disease. Which of the wifes descriptions of her husbands health and function is most suggestive of Parkinsons disease?
- A. Lately he seems to move far more slowly than he ever has in the past.
- B. He often complains that his joints are terribly stiff when he wakes up in the morning.
- C. Hes forgotten the names of some people that weve known for years.
- D. Hes losing weight even though he has a ravenous appetite.
Correct Answer: A
Rationale: Bradykinesia is a hallmark of Parkinson's disease. Joint stiffness, memory loss, or weight loss with increased appetite are not typical symptoms.
A male patient with a metastatic brain tumor is having a generalized seizure and begins vomiting. What should the nurse do first?
- A. Perform oral suctioning.
- B. Page the physician.
- C. Insert a tongue depressor into the patients mouth.
- D. Turn the patient on his side.
Correct Answer: D
Rationale: Turning the patient on their side prevents aspiration of vomit during a seizure. Tongue depressors are contraindicated, and suctioning or paging the physician are secondary actions.
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.
The nurse is caring for a patient who is scheduled for a cervical discectomy the following day. During health education, the patient should be made aware of what potential complications?
- A. Vertebral fracture
- B. Hematoma at the surgical site
- C. Scoliosis
- D. Renal trauma
Correct Answer: B
Rationale: Hematoma at the surgical site is a key complication of cervical diskectomy, risking cord compression. Fractures, scoliosis, or renal trauma are not typical risks.
The clinic nurse caring for a patient with Parkinsons disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. For what common side effect of Sinemet would the nurse assesses this patient?
- A. Pruritus
- B. Dyskinesia
- C. Lactose intolerance
- D. Diarrhea
Correct Answer: B
Rationale: Long-term levodopa use (5-10 years) commonly causes dyskinesia. Pruritus, lactose intolerance, and diarrhea are not typical side effects.