Nokea
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- A. Potential for injury.
- B. Powerlessness.
- C. Disturbed thought processes.
- D. Sexual dysfunction.
Correct Answer: B
Rationale: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (B). Injury (A) is physical, disturbed thought processes (C) relate to cognition, and sexual dysfunction (D) is not directly linked to aphasia.
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The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- A. Push aside any furniture.
- B. Place the client on his side.
- C. Assess the client’s vital signs.
- D. Ease the client to the floor.
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (D) prevents injury from falling. Clearing furniture (A) follows, placing on the side (B) is done after the client is safe, and vital signs (C) are assessed post-seizure.
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor?
- A. Nervousness, metastasis to the lungs, and seizures.
- B. Headache, vomiting, and papilledema.
- C. Hypotension, tachycardia, and tachypnea.
- D. Abrupt loss of motor function, diarrhea, and changes in taste.
Correct Answer: B
Rationale: The classic triad for brain tumors is headache, vomiting, and papilledema (B), due to increased ICP. Other options include unrelated or less specific symptoms.
Because the client with Parkinson's disease is prone to constipation, the nurse should encourage increased consumption of which food?
- A. Fresh fruits
- B. Wheat pasta
- C. Low-fat cheese
- D. Canned vegetables
Correct Answer: A
Rationale: Fresh fruits are high in fiber, which helps alleviate constipation in clients with Parkinson's disease.
Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'
- A. Explain to the client, 'Your mother died several years ago.'
- B. Tell the client, 'Your mother will visit later.'
- C. State, 'You miss your mother. What was she like?'
- D. Ask the client, 'When did you last see your mother?'
Correct Answer: C
Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.
The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next?
- A. Carefully remove the driver from the car.
- B. Assess the client's pupils for reaction.
- C. Assess the client's airway.
- D. Attempt to wake the client up by shaking him.
Correct Answer: C
Rationale: After cervical spine stabilization, ensuring a patent airway (C) is the next priority to support oxygenation. Removing the driver (A) risks further injury, pupil assessment (B) is secondary, and shaking (D) could worsen spinal injury.