Nokea
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
- A. Obtain a rubber mat to place under the dinner plate.
- B. Purchase a long-handled bath sponge for showering.
- C. Purchase clothes with Velcro closure devices.
- D. Obtain a raised toilet seat for the client's bathroom.
Correct Answer: B,C,D
Rationale: Generalized weakness post-stroke affects mobility and self-care. A long-handled bath sponge (B) aids bathing, Velcro clothes (C) simplify dressing, and a raised toilet seat (D) facilitates safe toileting. A rubber mat (A) is less relevant to generalized weakness.
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A 20-year-old female client who tried lysergic acid diethylamide (LSD) as a teen tells the nurse that she has bad dreams that make her want to kill herself. Which is the explanation for this occurrence?
- A. These occurrences are referred to as 'holdover reactions' to the drug.
- B. These are flashbacks to a time when the client had a 'bad trip.'
- C. The drug is still in the client’s body and causing these reactions.
- D. The client is suicidal and should be on one-to-one precautions.
Correct Answer: B
Rationale: LSD can cause flashbacks (B), where users re-experience effects like bad dreams years later, especially from a 'bad trip.' Holdover reactions (A) is not a term, LSD is not stored long-term (C), and suicidal ideation (D) requires assessment but is not the explanation.
The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
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.
Which client should the nurse assess first after receiving the shift report?
- A. The client diagnosed with a stroke who has right-sided paralysis.
- B. The client diagnosed with meningitis who complains of photosensitivity.
- C. The client with a brain tumor who has projectile vomiting.
- D. The client with epilepsy who complains of tender gums.
Correct Answer: C
Rationale: Projectile vomiting (C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (A), photosensitivity (B), and tender gums (D) are less urgent.