Nokea
The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position?
- A. Widening pulse pressure and bounding pulse.
- B. Diplopia and decreased visual acuity.
- C. Bradykinesia and scanning speech.
- D. Hemiparesis and personality changes.
Correct Answer: B
Rationale: Visual symptoms like diplopia and decreased visual acuity (B) can localize a tumor to areas affecting the optic pathways or occipital lobe. Other options are less specific to tumor location.
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When a client is injured during a seizure, which fact is most important to document on the incident (accident) report to reduce the risk of liability?
- A. The client was assigned to a licensed nurse.
- B. The signal cord was within the client's reach.
- C. The client's vital signs had been stable.
- D. The client was last observed reading.
Correct Answer: B
Rationale: Documenting that the signal cord was within reach indicates that safety measures were in place, reducing liability.
When the nurse describes the myelogram procedure to the client, which statement is most accurate?
- A. Part of the test involves a lumbar puncture.'
- B. You will be asked to change positions frequently.'
- C. Dye is instilled into a vein in your arm.'
- D. Light anesthesia is administered during the test.'
Correct Answer: A
Rationale: A myelogram involves a lumbar puncture to inject contrast dye into the spinal canal for imaging.
The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.
An older adult with PD is prescribed levodopa and carbidopa. What information should the nurse include when teaching the client and spouse?
- A. The client has an increased risk for falls.
- B. The client should stop taking multiple vitamins.
- C. The medication should not be taken with food.
- D. The medication has very few adverse effects.
Correct Answer: A
Rationale: When first taking levodopa/carbidopa (Sinemet), the client is likely to experience dizziness and orthostatic hypotension due to the dopamine agonist properties. The client and spouse must be alerted about the increased risk for falls. Levodopa/carbidopa can be taken with multiple vitamins. Levodopa/carbidopa can be taken with food to decrease GI upset. There are many, not few, adverse effects associated with levodopa/carbidopa, including involuntary movements, anxiety, memory loss, blurred vision, and mydriasis.
The nurse is caring for the client with encephalitis. Which intervention should the nurse implement first if the client is experiencing a complication?
- A. Examine pupil reactions to light.
- B. Assess level of consciousness.
- C. Observe for seizure activity.
- D. Monitor vital signs every shift.
Correct Answer: B
Rationale: Level of consciousness (B) is the first assessment for complications in encephalitis, indicating neurological status. Pupil reactions (A), seizures (C), and vital signs (D) follow.