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The client is diagnosed with ALS. As the disease progresses, which intervention should the nurse implement?
- A. Discuss the need to be placed in a long-term care facility.
- B. Explain how to care for a sigmoid colostomy.
- C. Assist the client to prepare an advance directive.
- D. Teach the client how to use a motorized wheelchair.
Correct Answer: C
Rationale: ALS progression leads to significant disability, making advance directives (C) critical to ensure the client’s wishes are respected. Long-term care (A) is premature, colostomy (B) is unrelated, and wheelchair use (D) is secondary.
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When the nursing team plans the care of a client with Guillain-Barré syndrome, which assessment finding most accurately determines whether the client is developing ineffective breathing?
- A. Respiratory rate is 24.
- B. Skin is flushed.
- C. Activity is decreased.
- D. Pulse oximetry reading is 82%.
Correct Answer: D
Rationale: A pulse oximetry reading of 82% indicates significant hypoxemia, suggesting ineffective breathing, which is a critical concern in Guillain-Barré syndrome due to potential respiratory muscle weakness.
Which nursing intervention is most effective in helping a client with aphasia communicate?
- A. Speak loudly and clearly to the client.
- B. Use simple pictures or a communication board.
- C. Ask the client to write responses to questions.
- D. Encourage the client to repeat words after the nurse.
Correct Answer: B
Rationale: A communication board or pictures aids communication for clients with aphasia by providing visual cues to express needs.
The nurse is caring for the client with a leaking cerebral aneurysm. What is the earliest sign that would indicate to the nurse that increased ICP may be developing?
- A. Change in pupil size and reaction
- B. Sudden drop in the blood pressure
- C. Experiencing diminished sensation
- D. Change in the level of consciousness
Correct Answer: D
Rationale: Pupillary changes may occur with ICP as it progresses, but they are not an early sign of developing ICP. A drop in BP is not directly associated with neurological deterioration. A BP with a wide pulse pressure is a late sign of increased ICP. Diminished sensation may occur with increased ICP, but it is not the earliest sign. A change in the level of consciousness is the first sign of neurological deterioration and is often associated with the development of increased ICP.
What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.
The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply.
- A. Maintain the head of the bed at 60 degrees of elevation.
- B. Administer stool softeners daily.
- C. Ensure the pulse oximeter reading is higher than 93%.
- D. Perform deep nasal suction every two (2) hours.
- E. Administer mild sedatives.
Correct Answer: B,C
Rationale: Stool softeners (B) prevent straining, which could increase ICP. Maintaining pulse oximetry >93% (C) ensures adequate oxygenation. High HOB elevation (A) may reduce cerebral perfusion, deep suction (D) risks increasing ICP, and sedatives (E) may mask neurological changes.