Nokea
If the diagnosis is accurate, which assessment findings should the nurse document? Select all that apply.
- A. Photophobia
- B. A stiff neck
- C. Muscle weakness
- D. Diarrhea
- E. Vertigo
- F. Fever
Correct Answer: A,B,F
Rationale: Meningitis commonly presents with photophobia, stiff neck (nuchal rigidity), and fever due to inflammation of the meninges. Muscle weakness, diarrhea, and vertigo are not typically associated with meningitis.
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Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?
- A. The client has cogwheel rigidity when moving the upper extremities.
- B. The client has a decrease in the frequency and severity of tremors.
- C. The client has less facial pain and converses with more facial expression.
- D. The client no longer experiences auras or a severe frontal headache.
Correct Answer: B
Rationale: Cogwheel rigidity, a symptom of PD, is interrupted muscular movement and is not treated with the DBS. DBS is a treatment used for intractable tremors associated with PD. The electrical current interferes with the brain cells initiating the tremors. Severe facial pain is associated with trigeminal neuralgia, not PD rau. The DBS will not affect facial expression. Auras are unusual sensations experienced before a seizure occurs and are not associated with PD.
The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
- A. Social worker.
- B. Chaplain.
- C. Health-care provider.
- D. Occupational therapist.
Correct Answer: A
Rationale: A social worker (A) can connect the family with community resources, financial aid, and support services. Chaplains (B) address spiritual needs, providers (C) focus on medical care, and occupational therapists (D) address functional deficits.
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
- A. Notify the health-care provider as soon as possible (ASAP).
- B. Calm the client down by talking therapeutically.
- C. Increase the IV rate by 50 mL/hour.
- D. Lower the head of the bed immediately.
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (D) restores cerebral perfusion. Notifying the provider (A) or increasing IV rate (C) follows, and talking therapeutically (B) does not address the urgent issue.
Which diagnostic test is used to confirm the diagnosis of Amyotrophic Lateral Sclerosis (ALS)?
- A. Electromyogram (EMG).
- B. Muscle biopsy.
- C. Serum creatine kinase (CK).
- D. Pulmonary function test.
Correct Answer: A
Rationale: EMG (A) detects abnormal muscle electrical activity characteristic of ALS, confirming the diagnosis. Muscle biopsy (B) is less specific, CK (C) may be elevated but isn’t diagnostic, and pulmonary tests (D) assess complications, not diagnosis.