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The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?
- A. Bell's palsy.
- B. Right-sided stroke.
- C. Tetany.
- D. Mononeuropathy.
Correct Answer: A
Rationale: Bell’s palsy (A) causes unilateral facial drooping, inability to wrinkle the forehead, and eye closure issues due to facial nerve paralysis. Right-sided stroke (B) affects the opposite side, tetany (C) involves muscle spasms, and mononeuropathy (D) is less specific.
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Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.
The client diagnosed with ALS asks the nurse, 'I know this disease is going to kill me. What will happen to me in the end?' Which statement by the nurse would be most appropriate?
- A. You are afraid of how you will die?'
- B. Most people with ALS die of respiratory failure.'
- C. Don’t talk like that. You have to stay positive.'
- D. ALS is not a killer. You can live a long life.'
Correct Answer: B
Rationale: Providing factual information about respiratory failure (B) addresses the client’s question honestly while respecting their need for clarity. Reflecting fear (A) is vague, dismissing concerns (C) is untherapeutic, and denying prognosis (D) is inaccurate.
Which nursing action is best for controlling the symptoms of the client diagnosed with myasthenia gravis?
- A. Ensure that the client has regular bowel and bladder elimination.
- B. Administer each dose of medication at the precise scheduled time.
- C. Encourage the client to exercise twice daily for 30 minutes.
- D. Monitor the client's blood pressure every 4 hours.
Correct Answer: B
Rationale: Precise timing of pyridostigmine administration ensures consistent symptom control in myasthenia gravis by maintaining acetylcholine levels.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
- A. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
- B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson’s disease.
- C. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training activities.
- D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
Correct Answer: A
Rationale: Feeding a client with swallowing difficulty (A) requires nursing judgment to assess aspiration risk, so it should not be delegated. Turning/positioning (B), assisting with toileting (C), and vital signs (D) are within UAP scope.
What should the nurse warn a client with multiple sclerosis to avoid?
- A. Hot weather
- B. Wet climates
- C. Your diet
- D. Cold temperatures
Correct Answer: A
Rationale: Hot weather can exacerbate MS symptoms by increasing body temperature, which impairs nerve conduction.