Nokea
In conducting the admission assessment for a client experiencing complications of long-term Parkinson's disease, which question by the nurse provides the best information about disease progression?
- A. Have you experienced any stiffness in your neck or shoulder?
- B. Do you notice any jerky-type movements of your arms?
- C. Have you ever been frozen to a spot and unable to move?
- D. Do you have any problems with your hands shaking?
Correct Answer: C
Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson's disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson's disease but do not specifically address the aspect of disease progression related to freezing episodes.
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When preparing the client for a thoracentesis, which action is essential for the nurse to take?
- A. Encourage the client to cough during the procedure
- B. Ask the client to void prior to the procedure
- C. Have the client lie in the prone position
- D. Determine if chest x-rays have been completed
Correct Answer: B
Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.
When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?
- A. Psychological counseling to address emotional well-being
- B. Medication teaching concerning adrenergic blockers
- C. Preoperative and postoperative teaching for adrenalectomy
- D. Education on dietary modifications for hypertension
Correct Answer: C
Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.
Why is it important to initiate nursing interventions that promote good nutrition, rest, exercise, and stress reduction for clients diagnosed with an HIV infection?
- A. Prevent the spread of infection to others
- B. Improve the function of the immune system
- C. Increase the ability to carry out activities of daily living
- D. Promote a feeling of general well-being
Correct Answer: B
Rationale: The correct answer is B: 'Improve the function of the immune system.' Initiating interventions focusing on good nutrition, rest, exercise, and stress reduction aims to enhance the immune system function in clients with HIV infection. For individuals with HIV, maintaining a strong immune system is crucial in fighting the virus and preventing opportunistic infections. Choices A, C, and D are important aspects of care but are secondary to the primary goal of boosting the immune system to combat the effects of the HIV virus.
Which entry in the client record best reflects significant data on a male client who is admitted with complaints of chest pain?
- A. Nurse will check client q1h for the presence of chest pain
- B. Client has a nervous, tense personality and is likely to overreact
- C. Client states he will notify the nurse if chest pain returns
- D. Client understands how to use the call button and the telephone
Correct Answer: C
Rationale: The correct answer is C because documenting the client's statement about notifying the nurse if chest pain returns provides direct, relevant information about their condition. This entry indicates the client's awareness of their symptoms and their willingness to seek assistance, which is crucial in managing chest pain. Choice A is incorrect because it focuses on the nurse's actions rather than the client's condition. Choice B is irrelevant as it discusses the client's personality rather than their current health issue. Choice D, though related to communication, does not directly address the client's chest pain complaint.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Describes a schedule for antacid use in combination with other prescribed medications
- B. Selects a pattern of small meals interspersed with fluid intake
- C. Commits to engaging in a variety of stress reduction techniques
- D. Expresses a commitment to decrease nicotine intake
Correct Answer: B
Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.