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 client recovering at home following a stapedectomy for otosclerosis reports having dizziness. To decrease symptoms, which interventions should the nurse recommend? Select all that apply.
- A. Refrain from sudden movements.
- B. Avoid chewing on the affected side.
- C. Avoid lifting objects that are heavy.
- D. Minimize bending over at the waist.
- E. Restrict the intake of oral fluids.
Correct Answer: A,C,D
Rationale: Refraining from sudden movements, avoiding heavy lifting, and minimizing bending decrease dizziness by reducing fluid shifts in the inner ear. Chewing and fluid restriction do not affect dizziness.
The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client?
- A. Administer dilating drops to both eyes for 72 hours prior to surgery.
- B. Prior to surgery do not lift or push any objects heavier than 15 pounds.
- C. Make arrangements for being in the hospital for at least three (3) days.
- D. Avoid taking any type of medication which may cause bleeding, such as aspirin.
Correct Answer: D
Rationale: Avoiding bleeding-risk medications like aspirin prevents intraoperative hemorrhage. Dilating drops are not used for 72 hours, lifting restrictions are postoperative, and cataract surgery is typically outpatient.
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 with cataracts who has had intraocular lens implants is being discharged from the day surgery department. Which discharge instructions should the nurse discuss with the client?
- A. Do not push or pull objects heavier than 50 pounds.
- B. Lie on the affected eye with two pillows at night.
- C. Wear glasses or metal eye shields at all times.
- D. Bend and stoop carefully for the rest of your life.
Correct Answer: C
Rationale: Wearing eye shields protects the eye post-cataract surgery, especially at night. Heavy lifting is restricted lighter, lying on the affected eye is avoided, and lifelong bending restrictions are excessive.
The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client?
- A. Suggest using extra seasoning when cooking.
- B. Instruct the client to keep a seven (7)-day food diary.
- C. Refer the client to a dietitian immediately.
- D. Recommend eating three (3) meals a day.
Correct Answer: B
Rationale: A food diary identifies intake patterns and weight loss causes, guiding intervention. Extra seasoning is premature, dietitian referral is secondary, and three meals are standard advice.