Nokea
The client is diagnosed with a brain abscess. Which sign/symptom is the most common?
- A. Projectile vomiting.
- B. Disoriented behavior.
- C. Headaches, worse in the morning.
- D. Petit mal seizure activity.
Correct Answer: C
Rationale: Brain abscesses cause increased ICP, leading to headaches worse in the morning (C). Vomiting (A) is less specific, disorientation (B) is secondary, and petit mal seizures (D) are less common.
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Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
For a client with Guillain-Barré syndrome, which complication should the nurse monitor most closely?
- A. Urinary incontinence
- B. Deep vein thrombosis
- C. Hypertension
- D. Hypoglycemia
Correct Answer: B
Rationale: Deep vein thrombosis is a significant risk in Guillain-Barré syndrome due to immobility from muscle weakness.
The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
- A. Social worker.
- B. Chaplain.
- C. Health-care provider.
- D. Occupational therapist.
Correct Answer: A
Rationale: A social worker (A) can connect the family with community resources, financial aid, and support services. Chaplains (B) address spiritual needs, providers (C) focus on medical care, and occupational therapists (D) address functional deficits.
Which clinical manifestation is the educator most likely to include as the initial sign of Parkinson's disease?
- A. Muscle rigidity
- B. Muscle tremors
- C. Muscle weakness
- D. Muscle deterioration
Correct Answer: B
Rationale: Muscle tremors, particularly resting tremors, are often the initial sign of Parkinson's disease.
When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?
- A. 1/4'' (0.6 cm)
- B. 1/2'' (1.3 cm)
- C. 1'' (2.5 cm)
- D. 2'' (5 cm)
Correct Answer: C
Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.