Nokea
The client diagnosed with a right-sided cerebrovascular accident is admitted to the rehabilitation unit. Which interventions should be included in the nursing care plan? Select all that apply.
- A. Position the client to prevent shoulder adduction.
- B. Turn and reposition the client every shift.
- C. Encourage the client to move the affected side.
- D. Perform quadriceps exercises three (3) times a day.
- E. Instruct the client to hold the fingers in a fist.
Correct Answer: A,C,D
Rationale: For a right-sided CVA, the left side is affected. Positioning to prevent shoulder adduction (A) supports the weak left arm to prevent contractures. Encouraging movement of the affected side (C) promotes neuroplasticity and recovery. Quadriceps exercises (D) strengthen the affected leg. Turning every shift (B) is too infrequent; every 2 hours is standard to prevent pressure ulcers. Instructing to hold fingers in a fist (E) risks contractures and is not therapeutic.
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Which discharge instruction is most important for a client with a herniated disk?
- A. Sleep on a soft mattress.
- B. Perform high-impact exercises.
- C. Maintain proper body mechanics.
- D. Take hot baths daily.
Correct Answer: C
Rationale: Proper body mechanics prevent re-injury and promote healing in clients with a herniated disk.
The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply.
- A. Nuchal rigidity
- B. Severe headache
- C. Pill-rolling tremor
- D. Photophobia
- E. Lethargy
Correct Answer: A,B,D,E
Rationale: Irritation of the meninges causes nuchal rigidity (stiff neck). Irritation of the meninges causes severe headache. Pill-rolling tremors are associated with PD. Irritation of the meninges causes photophobia (light irritates the eyes). Lethargy, pathological state of sleepiness or unresponsiveness, indicates a decreased level of consciousness which is associated with meningitis.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
When the nursing team discusses the client's plan of care, which has the highest priority?
- A. Teaching the client about prevention of skin breakdown
- B. Strengthening the client's upper body muscles
- C. Confronting the client's denial of the prognosis
- D. Letting the client verbalize about the accident
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement prior to the procedure?
- A. Determine if the client has claustrophobia.
- B. Obtain a signed informed consent form.
- C. Determine if the client is allergic to egg yolks.
- D. Start an intravenous line in both hands.
Correct Answer: A
Rationale: MRI involves a confined space, so assessing for claustrophobia (A) ensures patient comfort and safety. Consent (B) is required but secondary, egg yolk allergy (C) is irrelevant, and bilateral IVs (D) are unnecessary.