Nokea
Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain?
- A. Spinal tumor
- B. Arthritic joint
- C. Muscle strain
- D. Shingles
- E. Kidney stones
Correct Answer: A,D
Rationale: Spinal tumors and shingles cause neuropathic pain due to nerve involvement.
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In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia?
- A. Hypotension
- B. Sudden headache
- C. Flushed face
- D. Nasal congestion
- E. Profuse sweating above the level of the injury
Correct Answer: B,C,D,E
Rationale: Autonomic dysreflexia causes headache, flushing, nasal congestion, and sweating above the injury level due to sympathetic overactivity.
The nurse is performing an assessment on a client with Wernicke's aphasia. Which client finding would be consistent with this diagnosis?
- A. Loss of ability to execute or carry out skilled movements.
- B. Cannot express any words.
- C. Cannot swallow liquids.
- D. Speaks with normal fluency and prosody.
Correct Answer: D
Rationale: Wernicke's aphasia is characterized by fluent but nonsensical speech with preserved fluency and prosody.
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
- A. Place an eye patch over the affected eye
- B. Instruct the client to turn their head from side to side
- C. Speak slowly, clearly, and in a deeper voice
- D. Provide the client with ear plugs to promote rest
Correct Answer: B
Rationale: Head turning compensates for the visual field loss in homonymous hemianopia.
The nurse is assessing a client with Guillain-Barré syndrome. Which of the following would be an expected finding?
- A. Hyperreflexia
- B. Perseveration
- C. Dystonia
- D. Paresthesia
Correct Answer: D
Rationale: Paresthesia (tingling/numbness) is common in Guillain-Barré syndrome due to peripheral nerve demyelination.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
- A. If my gums get irritated and large, I can stop this medication.
- B. I will need laboratory work to monitor the medication level.
- C. It is okay for me to increase this medication if I have a seizure.
- D. I should take this medication with low protein foods.
Correct Answer: B
Rationale: Phenytoin requires regular blood level monitoring to ensure therapeutic levels (10-20 mcg/mL). Stopping due to gum hyperplasia, increasing doses without medical advice, or taking with low-protein foods are incorrect.