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 a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement?
- A. Keep the client flat in bed.
- B. Dim the lights in the room.
- C. Assess for bladder distention.
- D. Administer a narcotic analgesic.
Correct Answer: C
Rationale: Severe headache and hypertension in C6 SCI suggest autonomic dysreflexia, often triggered by bladder distention (C). Assessing and relieving the trigger is the priority. Flat positioning (A) may worsen symptoms, dimming lights (B) is not effective, and narcotics (D) do not address the cause.
The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving?
- A. The current GSC rating is 3.
- B. The current GSC rating is 9.
- C. The current GSC rating is 10.
- D. The current GSC rating is 12.
Correct Answer: D
Rationale: A GCS of 12 (D) is higher than 10, indicating improved neurological status. Scores of 3 (A) or 9 (B) indicate worsening, and 10 (C) shows no change.
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.
Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
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.