Nokea
Assessment of a client with a history of stroke reveals that the client understands and follows commands but answers questions with incorrect word choices. The nurse documents the presence of which communication deficit?
- A. Aphasia
- B. Apraxia
- C. Dysarthria
- D. Dysphagia
Correct Answer: A
Rationale: Aphasia (A) is a language disorder causing difficulty with word choice or expression, common in stroke affecting language centers. The client’s ability to follow commands but use incorrect words suggests expressive aphasia. Apraxia (B) affects motor planning, dysarthria (C) impairs speech articulation, and dysphagia (D) involves swallowing difficulties, none of which match the described deficit.
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An adult is admitted with meningitis. During the acute phase of the illness, which measure should the nurse include in the nursing care plan to reduce the chance of seizures?
- A. Play the client's favorite music.
- B. Stimulate the client every two hours.
- C. Keep a padded tongue blade at the bedside.
- D. Darken the client's room.
Correct Answer: D
Rationale: Darkening the room minimizes sensory stimulation, reducing seizure risk in meningitis, where neurological irritability is common.
While teaching the family of a child who will take phenytoin (Dilantin) regularly for seizure control, it is most important for the nurse to teach them about which of the following actions?
- A. Maintain good oral hygiene and dental care
- B. Omit medication if the child is seizure free
- C. Administer acetaminophen to promote sleep
- D. Serve a diet that is high in iron
Correct Answer: A
Rationale: Swollen and tender gums occur often with use of phenytoin. Good oral hygiene and regular visits to the dentist should be emphasized.
The nurse is reviewing new medication prescriptions for a client with an acute exacerbation of asthma. Which of the following prescriptions should the nurse clarify?
- A. Albuterol 2.5 mg via nebulizer every 4 hours
- B. Potassium chloride 20 mEq (20 mmol) IV every 24 hours
- C. Enoxaparin 40 mg subcutaneously every 24 hours
- D. Methylprednisolone sodium succinate 20 mg IV every 6 hours
Correct Answer: B
Rationale: Potassium chloride (B) is not indicated for asthma exacerbation unless hypokalemia is documented, requiring clarification. Albuterol (A), methylprednisolone (D) treat asthma, and enoxaparin (C) may prevent thrombosis in immobile patients.
The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
- A. Do not worry. Epilepsy can be treated with medications.
- B. The seizure may or may not mean your child has epilepsy.
- C. Since this was the first convulsion, it may not happen again.
- D. Long term treatment will prevent future seizures.
Correct Answer: B
Rationale: The seizure may or may not mean your child has epilepsy. A single seizure has multiple potential causes, not necessarily epilepsy.
A male client is admitted for evaluation of a sudden hearing loss. No physical cause can be found for his sudden deafness; however, a friend reveals that the client's fiancée recently canceled their engagement, saying that she needed more time to think about the marriage. The client's deafness is an example of:
- A. Conversion reaction
- B. Hypochondriasis
- C. Reaction formation
- D. Histrionic personality disorder
Correct Answer: A
Rationale: Sudden deafness after emotional stress, without physical cause, indicates a conversion reaction, where psychological distress manifests physically.