Nokea
The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?
- A. Muscle atrophy and flaccidity.
- B. Fatigue and malnutrition.
- C. Slurred speech and dysphagia.
- D. Weakness and paralysis.
Correct Answer: C
Rationale: Slurred speech and dysphagia (C) are early ALS signs due to bulbar muscle involvement. Atrophy/flaccidity (A) and weakness/paralysis (D) occur later, and fatigue/malnutrition (B) are nonspecific.
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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.
When the medical history is reviewed, which finding is most likely related to the client's diagnosis?
- A. The client had an influenza immunization in the past week.
- B. The client was bitten by a spider several days ago.
- C. The client drinks fresh, unpasteurized milk daily.
- D. The client sprayed the garden with insecticide yesterday.
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral infection or immunization, such as an influenza vaccine, which can trigger an autoimmune response.
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.
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.
The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?
- A. MRIs are loud but there will not be any invasive procedure done.'
- B. You’re scared. Tell me about what is scaring you.'
- C. This is the least thing to be scared about—there will be worse.'
- D. I can call the MRI tech to come and talk to you about the scan.'
Correct Answer: B
Rationale: Reflecting the client’s fear (B) encourages expression of concerns, fostering therapeutic communication. Other options provide information (A, D) or minimize feelings (C).