Nokea
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
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If the client begins to have a seizure after the EEG, which action should the nurse take first?
- A. Administer oxygen by nasal cannula.
- B. Measure the blood pressure and pulse.
- C. Check the client's pupils.
- D. Place the client in a side-lying position.
Correct Answer: D
Rationale: Placing the client in a side-lying position prevents aspiration and maintains airway patency during a seizure.
Which instruction should be the nurse's priority in this situation?
- A. Steps to enhance the client's immune system
- B. Importance of maintaining a balanced diet
- C. Techniques to improve the client's safety
- D. Importance of social interactions
Correct Answer: C
Rationale: Safety is the priority for clients with Parkinson's disease due to risks of falls and injury from motor symptoms.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.
The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan?
- A. Ensure the traction weight hangs freely
- B. Remove the vest from the device at bedtime
- C. Cleanse sites where the pins enter the skull
- D. Screw the pins in the skull daily to tighten.
Correct Answer: C
Rationale: Neither traction nor weights are part of the halo device. The halo external fixation device includes a vest that is worn continuously and should not be removed. The neurosurgeon will discontinue it when the injury has stabilized and sufficient healing has occurred. A halo external fixation device is a static device that consists of a “halo” that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pin sites. The nurse should not tighten the pins. These are secured in the skull to maintain alignment of the cervical vertebrae. If loose, the nurse should contact the HCP for tightening.
When the client is observed wandering about the facility, the nurse modifies the client's care plan to provide for safety. Which nursing intervention is most appropriate at this time?
- A. Keep the client confined to the room.
- B. Attach an identity tag to the client's clothes.
- C. Lock all the outside doors in the facility.
- D. Make sure the client knows the location of the facility.
Correct Answer: B
Rationale: An identity tag helps ensure the client can be identified and returned safely if they wander, promoting safety without restricting freedom.