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The client diagnosed with delirium tremens when trying to quit drinking cold turkey is admitted to the medical unit. Which medications would the nurse anticipate administering?
- A. Thiamine (vitamin B6) and librium, a benzodiazepine.
- B. Dilantin, an anticonvulsant, and Feosol, an iron preparation.
- C. Methadone, a synthetic narcotic, and Depakote, a mood stabilizer.
- D. Mannitol, an osmotic diuretic, and Ritalin, a stimulant.
Correct Answer: A
Rationale: Delirium tremens requires thiamine (vitamin B1, not B6) to prevent Wernicke’s encephalopathy and benzodiazepines like Librium (A) to manage withdrawal symptoms. Other options are unrelated to delirium tremens management.
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The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of 'impaired nutrition.' Which nursing intervention would be included in the plan of care?
- A. Consult the occupational therapist for adaptive appliances for eating.
- B. Request a low-fat, low-sodium diet from the dietary department.
- C. Provide three (3) meals per day that include nuts and whole-grain breads.
- D. Offer six (6) meals per day with a soft consistency.
Correct Answer: A
Rationale: PD can impair fine motor skills, making eating difficult. Consulting an occupational therapist (A) for adaptive appliances supports nutritional intake. Low-fat diets (B) are not specific, nuts/breads (C) may be hard to chew, and six soft meals (D) may not address motor issues.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?
- A. Positive Babinski’s sign and peripheral paresthesia.
- B. Negative Chvostek’s sign and facial tingling.
- C. Positive Kernig’s sign and nuchal rigidity.
- D. Negative Trousseau’s sign and nystagmus.
Correct Answer: C
Rationale: Kernig’s sign (pain with leg extension) and nuchal rigidity (C) are hallmark signs of bacterial meningitis due to meningeal irritation. Other options include unrelated or less specific findings.
The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
The nurse researcher is working with clients diagnosed with Parkinson’s disease. Which is an example of an experimental therapy?
- A. Stereotactic pallidotomy/thalamotomy.
- B. Dopamine receptor agonist medication.
- C. Physical therapy for muscle strengthening.
- D. Fetal tissue transplantation.
Correct Answer: D
Rationale: Fetal tissue transplantation (D) is an experimental therapy for Parkinson’s, investigated for dopamine-producing cell replacement. Pallidotomy/thalamotomy (A) and dopamine agonists (B) are established, and physical therapy (C) is standard care.