Nokea
A stroke victim regains consciousness three days after admission. She has right-sided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following?
- A. Stay with her and give her time and encouragement in attempting to speak.
- B. Say, 'I'm sure you want a glass of water. I'll get it for you.'
- C. Say, 'Don't get upset. You rest now and I'll come back later and try to talk to you then.'
- D. Encourage her attempts and say, 'Don't worry, it will get easier every day.'
Correct Answer: A
Rationale: Staying with the client and offering encouragement supports her attempts to speak, fostering communication and emotional support.
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The charge nurse is admitting a 90-year-old client to a long-term care facility. Which intervention should the nurse implement?
- A. Ensure the client's room temperature is cool.
- B. Talk louder to make sure the client hears clearly.
- C. Complete the admission as fast as possible.
- D. Provide extra orientation to the surroundings.
Correct Answer: D
Rationale: Extra orientation helps elderly clients with sensory deficits adjust to new environments, enhancing safety. Cool rooms, loud talking, and rushed admissions are less effective.
A 27-year-old woman is admitted to the hospital complaining of numbness in both legs, difficulty walking, and double vision of one week in duration. Multiple sclerosis is suspected. Orders include bed rest with bathroom privileges, brain scan, EEG, lumbar puncture, adrenocorticotropic hormone (ACTH) 40 units intramuscularly (IM) bid x 3 days, then 30 units IM bid x 3 days, then 20 units IM bid x 3 days; and passive range of motion (ROM) progressing to active ROM as tolerated. In planning care for this client, which activity is most important to include?
- A. Encouraging her to perform all care activities for herself
- B. Frequent ambulation to retain joint mobility
- C. Scheduling frequent rest periods between physical activity
- D. Feeding the client to reduce energy needs
Correct Answer: C
Rationale: Frequent rest periods are essential to manage fatigue, a common symptom in multiple sclerosis, while supporting activity as tolerated.
The client is one day post-surgical repair of a retinal detachment. Which assessment finding is most important for the nurse to report immediately to the HCP because it indicates a significant complication?
- A. Surgical eye pain rated 2 on a 10-point scale
- B. Increased tearing from the surgical eye
- C. Blurred vision and floaters in the surgical eye
- D. Dryness and injection of the sclera in the surgical eye
Correct Answer: C
Rationale: Blurred vision and floaters in the surgical eye may occur with redetachment of the retina and would warrant additional surgery. A low level of postoperative pain does not indicate a significant complication. Watery drainage is not a specific sign for concern and is less serious than changes in visual acuity. Dryness and injection of the sclera may or may not resolve without treatment, but loss of visual acuity is a more critical sign of complication.
The day following a stapedectomy, the client tells the nurse that he cannot hear much in the operative ear and thinks the stapedectomy was a failure. What is the best response for the nurse to make?
- A. There is packing in your ear. You will not hear well for a few days.'
- B. The doctors have not yet turned on the stapes replacement.'
- C. You may not have hearing, but you will now be free of pain.'
- D. You seem upset that you aren't hearing well.'
Correct Answer: A
Rationale: Ear packing post-stapedectomy temporarily reduces hearing, which improves as packing is removed.
The nurse is administering eyedrops to the client. Which guidelines should the nurse adhere to when instilling the drops into the eye? Select all that apply.
- A. Do not touch the tip of the medication container to the eye.
- B. Apply gentle pressure on the outer canthus of the eye.
- C. Apply sterile gloves prior to instilling eyedrops.
- D. Hold the lower lid down and instill drops into the conjunctiva.
- E. Gently pat the skin to absorb excess eyedrops on the cheek.
Correct Answer: A,D,E
Rationale: Avoiding container contact prevents contamination, instilling into the conjunctiva ensures absorption, and patting excess drops maintains hygiene. Pressure on the outer canthus is incorrect (nasolacrimal duct pressure prevents systemic absorption), and sterile gloves are unnecessary.