Nokea
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client’s spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?
- A. “Plasmapheresis removes excess fluid from the bloodstream.”
- B. “Plasmapheresis will increase the protein levels in the blood.”
- C. “Plasmapheresis removes circulating antibodies from the blood.”
- D. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”
Correct Answer: C
Rationale: Aquapheresis or dialysis, not plasmapheresis, will remove excess fluid from the blood. Plasmapheresis does not increase protein levels in the blood. Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client. Plasmapheresis does not involve infusing lipoproteins.
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If the client begins to have a seizure after the EEG, which action should the nurse take first?
- A. Administer oxygen by nasal cannula.
- B. Measure the blood pressure and pulse.
- C. Check the client's pupils.
- D. Place the client in a side-lying position.
Correct Answer: D
Rationale: Placing the client in a side-lying position prevents aspiration and maintains airway patency during a seizure.
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
The nurse identifies the concept of intracranial regulation disturbance in a client diagnosed with Parkinson’s Disease. Which priority intervention should the nurse implement?
- A. Keep the bed low and call light in reach.
- B. Provide a regular diet of three (3) meals per day.
- C. Obtain an order for home health to see the client.
- D. Perform the Braden scale skin assessment.
Correct Answer: A
Rationale: Parkinson’s increases fall risk due to bradykinesia and rigidity. Keeping the bed low and call light in reach (A) prioritizes safety. Diet (B), home health (C), and skin assessment (D) are secondary.
Which intervention is most appropriate for a client with multiple sclerosis experiencing fatigue?
- A. Schedule activities in the late afternoon.
- B. Encourage short, frequent rest periods.
- C. Administer caffeine supplements.
- D. Increase physical therapy sessions.
Correct Answer: B
Rationale: Short, frequent rest periods help manage fatigue in multiple sclerosis by conserving energy.
The client is diagnosed with Creutzfeldt-Jakob disease. Which referral would be the most appropriate?
- A. Alzheimer's Association.
- B. Creutzfeldt-Jakob Disease Foundation.
- C. Hospice care.
- D. A neurosurgeon.
Correct Answer: B
Rationale: The Creutzfeldt-Jakob Disease Foundation (B) provides specialized support and resources. Alzheimer’s Association (A) is unrelated, hospice (C) may be premature, and neurosurgery (D) is not typically indicated.