Nokea
The client has right homonymous hemianopia following an ischemic stroke. The nurse asks the NA to help the client with meals knowing that this problem may result in which client response?
- A. Tendency to fall to the contralateral side
- B. Eating food on only half of the plate
- C. Using the silverware inappropriately
- D. Choking when swallowing any liquids
Correct Answer: B
Rationale: Tendency to fall to the contralateral side would be a concern if the client were weak or paralyzed. Homonymous hemianopia (hemianopsia) is a visual field abnormality that results in blindness in half of the visual field in the same side of both eyes. It results from damage to the optic tract or occipital lobe. Using the silverware inappropriately is a concern if the client has agnosia. Choking when swallowing any liquids is a concern if the client has dysphagia.
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The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding?
- A. A residual of 125 mL.
- B. The abdomen is soft.
- C. Three episodes of diarrhea.
- D. The potassium level is 3.4 mEq/L.
Correct Answer: A
Rationale: A gastric residual of 125 mL (A) indicates delayed gastric emptying, requiring the feeding to be held to prevent aspiration. Soft abdomen (B) is normal, diarrhea (C) requires monitoring but not holding, and low potassium (D) is unrelated.
Which medication should the nurse administer first during a prolonged seizure?
- A. Phenytoin (Dilantin) IV
- B. Lorazepam (Ativan) IV
- C. Levetiracetam (Keppra) oral
- D. Carbamazepine (Tegretol) oral
Correct Answer: B
Rationale: Lorazepam IV is the first-line treatment for status epilepticus to rapidly stop seizure activity.
The nurse is conducting a support group for clients diagnosed with Parkinson’s disease and their significant others. Which information regarding psychosocial needs should be included in the discussion?
- A. The client should discuss feelings about being placed on a ventilator.
- B. The client may have rapid mood swings and become easily upset.
- C. Pill-rolling tremors will become worse when the medication is wearing off.
- D. The client may automatically start to repeat what another person says.
Correct Answer: B
Rationale: Rapid mood swings and emotional upset (B) are common in Parkinson’s due to dopamine fluctuations, addressing psychosocial needs. Ventilator discussions (A) are irrelevant, tremors (C) are physical, and echolalia (D) is not typical.
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.
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.