Nokea
The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
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Because carbamazepine (Tegretol) can cause liver dysfunction, the client's discharge plan should include instructions to report which symptom?
- A. Unusual bleeding
- B. Yellowing of the skin
- C. Cloudy urine
- D. Mottled skin
Correct Answer: B
Rationale: Yellowing of the skin (jaundice) indicates potential liver dysfunction, a known side effect of carbamazepine.
Which collaborative intervention should the nurse implement when caring for the client with West Nile virus?
- A. Complete neurovascular examinations every eight (8) hours.
- B. Maintain accurate intake and output at the end of each shift.
- C. Assess the client’s symptoms to determine if there is improvement.
- D. Administer intravenous fluids while assessing for overload.
Correct Answer: D
Rationale: IV fluids (D) support hydration in West Nile virus while monitoring for overload prevents complications. Neurovascular exams (A) are less relevant, intake/output (B) is routine, and symptom assessment (C) is nursing-driven.
Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease)?
- A. Discuss a percutaneous gastrostomy tube.
- B. Explain how a fistula is accessed.
- C. Provide an advance directive.
- D. Refer to a physical therapist for leg braces.
Correct Answer: C
Rationale: ALS is progressive and terminal. Providing an advance directive (C) ensures the client’s wishes are respected early. Gastrostomy (A) is later, fistulas (B) are unrelated, and leg braces (D) are less urgent.
A family member brings the client to the emergency department reporting that the 78-year-old father has suddenly become very confused and thinks he is living in 1942, that he has to go to war, and that someone is trying to poison him. Which question should the nurse ask the family member?
- A. Has your father been diagnosed with dementia?'
- B. What medication has your father taken today?'
- C. What have you given him that makes him think it's poison?'
- D. Does your father like to watch old movies on television?'
Correct Answer: B
Rationale: Sudden confusion and delusions suggest delirium, often medication-related. Asking about medications (B) identifies potential causes. Dementia (A) causes gradual decline, blaming poison (C) is untherapeutic, and movies (D) are irrelevant.
The home-care nurse is counseling the client who has MS. The client is experiencing weakness, ataxia, intermittent adductor spasms of the hips, and occasional incontinence from loss of bladder sensation. Which self-care measures should the nurse recommend? Select all that apply.
- A. “Adductor spasms can be relieved by taking a hot bath.”
- B. “If a muscle is in spasm, stretch and hold it, and then relax.”
- C. “Rest first and then walk as able using a walker for support.”
- D. “When walking, keep feet close together, legs slightly bent.”
- E. “Set an alarm to remind you to void 30 minutes after fluid intake.”
Correct Answer: B,C,E
Rationale: Hot baths should be avoided; increasing the body temperature can exacerbate symptoms. Burns can occur with sensory loss associated with MS. A stretch—hold—relax routine is often helpful for relaxing the muscle and treating muscle spasms. Walking will help improve the gait, strengthen weakened muscles, and help relieve spasticity in the legs. If a muscle group is irreversibly affected by MS, other muscles can learn to compensate. A walker should be used for safety to help prevent falling. Widening the base of support increases walking stability, especially if ataxia (incoordination) is present; if feet are close together it increases the risk for a fall. Drinking fluids and then using an alarm to void 30 minutes later may be helpful in reducing incontinence from loss of bladder sensation.