Nokea
The client is diagnosed with ALS. Which client problem would be most appropriate for this client?
- A. Disuse syndrome.
- B. Altered body image.
- C. Fluid and electrolyte imbalance.
- D. Alteration in pain.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness, leading to disuse syndrome (A) from immobility. Body image (B) is secondary, fluid/electrolyte issues (C) are not primary, and pain (D) is less common.
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The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first?
- A. Set the ventilator to hyperventilate the client in preparation for suctioning.
- B. Assess the client’s lung sounds and check for peripheral cyanosis.
- C. Turn the client to the side to allow the secretions to drain from the mouth.
- D. Suction the client using the in-line suction, wait 30 seconds, and repeat.
Correct Answer: C
Rationale: Pooled secretions risk airway obstruction. Turning to the side (C) clears the airway safely without increasing ICP. Hyperventilation (A) and suctioning (D) may raise ICP, and assessment (B) delays intervention.
Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
- A. A subcutaneous anticoagulant.
- B. An intravenous osmotic diuretic.
- C. An oral anticonvulsant.
- D. An oral proton pump inhibitor.
Correct Answer: A
Rationale: Subcutaneous anticoagulants (A) increase bleeding risk in head injury patients, where intracranial hemorrhage is a concern, and should be questioned. Osmotic diuretics (B) reduce ICP, anticonvulsants (C) prevent seizures, and proton pump inhibitors (D) protect against stress ulcers.
Which assessment finding is especially important to monitor when caring for a client with myasthenia gravis who is in crisis?
- A. Breathing
- B. Temperature
- C. Blood pressure
- D. Mental status
Correct Answer: A
Rationale: Respiratory muscle weakness in myasthenic crisis can lead to respiratory failure, making breathing the most critical assessment.
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?
- A. There will be fewer side effects with this combination than with carbidopa alone.
- B. Dopamine D requires the presence of both of these medications to work.
- C. Carbidopa makes more levodopa available to the brain.
- D. Carbidopa crosses the blood-brain barrier to treat Parkinson’s disease.
Correct Answer: C
Rationale: Carbidopa inhibits peripheral breakdown of levodopa, allowing more levodopa to cross the blood-brain barrier and convert to dopamine (C). This enhances efficacy and reduces side effects. Other options are incorrect.