Nokea
The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client?
- A. Hospice nurse.
- B. Speech therapist.
- C. Physical therapist.
- D. Occupational therapist.
Correct Answer: B
Rationale: Glossopharyngeal nerve paralysis affects swallowing and speech. A speech therapist (B) is most appropriate to address these deficits. Hospice (A) is for end-of-life care, physical therapy (C) focuses on mobility, and occupational therapy (D) addresses daily activities.
You may also like to solve these questions
The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem 'altered cerebral tissue perfusion'?
- A. The client will be able to complete activities of daily living.
- B. The client will be protected from injury if seizure activity occurs.
- C. The client will be afebrile for 48 hours prior to discharge.
- D. The client will have elastic tissue turgor with ready recoil.
Correct Answer: B
Rationale: Altered cerebral perfusion in meningitis may lead to seizures. Protecting from injury during seizures (B) addresses this risk. ADLs (A), fever (C), and tissue turgor (D) are unrelated to perfusion.
The nurse is enjoying a day at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health-care provider to respond to the accident. Which intervention should be implemented first?
- A. Assess the client's level of consciousness.
- B. Organize onlookers to remove the client from the lake.
- C. Perform a head-to-toe assessment to determine injuries.
- D. Stabilize the client's cervical spine.
Correct Answer: D
Rationale: In trauma with potential head or neck injury, stabilizing the cervical spine (D) is the first priority to prevent spinal cord injury during movement. Assessing consciousness (A), organizing removal (B), or performing a full assessment (C) follows.
The nurse is assessing the client admitted with encephalitis. Which data require immediate nursing intervention? The client has bilateral facial palsies.
- A. The client has a recurrent temperature of 100.6°F.
- B. The client has a decreased complaint of headache.
- C. The client comments that the meal has no taste.
Correct Answer: B
Rationale: A fever of 100.6°F (B) in encephalitis may indicate worsening infection or inflammation, requiring immediate intervention. Decreased headache (C) suggests improvement, and taste loss (D) is less urgent. Facial palsies are noted but not an option.
How can the nurse best help the client deal with personal fears at this time?
- A. Encourage the client to verbalize feelings.
- B. Provide a detailed explanation of the disease progression.
- C. Tell the client about physical assessment findings.
- D. Explain that the disease may become periodically acute.
Correct Answer: A
Rationale: Encouraging verbalization of feelings helps the client process fears and promotes emotional coping during an MS exacerbation.