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The client, who had a stroke, follows the nurse’s instructions without problems, but an attempt to verbally respond to the nurse’s question was garbled. The nurse should identify that the client has which type of aphasia?
- A. Receptive aphasia
- B. Global aphasia
- C. Expressive aphasia
- D. Anomic aphasia
Correct Answer: C
Rationale: With receptive aphasia (Wernicke’s aphasia or fluent aphasia) the client would hear the voice but would be unable to comprehend the meaning of the message. Global aphasia is a combination of receptive and expressive aphasia. The client would have difficulty speaking and understanding words and would not be able to read or write. The nurse should identify that the client has expressive aphasia (Broca’s aphasia or non-fluent aphasia). The client is able to comprehend and responds appropriately. The client may attempt to speak but has difficulty communicating with the correct words. With anomic aphasia, the client would have word-finding difficulties; this client does not verbalize.
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Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
The nurse is caring for several clients on a medical unit. Which client should the nurse assess first?
- A. The client with ALS who is refusing to turn every two (2) hours.
- B. The client with abdominal pain who is complaining of nausea.
- C. The client with pneumonia who has a pulse oximeter reading of 90%.
- D. The client who is complaining about not receiving any pain medication.
Correct Answer: C
Rationale: A pulse oximetry of 90% (C) indicates hypoxemia, requiring immediate assessment to prevent respiratory compromise. Refusing turning (A), nausea (B), and pain complaints (D) are less urgent.
The client diagnosed with a brain tumor was admitted to the intensive care unit with decorticate posturing. Which indicates that the client’s condition is becoming worse?
- A. The client has purposeful movement with painful stimuli.
- B. The client has assumed adduction of the upper extremities.
- C. The client is aimlessly thrashing in the bed.
- D. The client has become flaccid and does not respond to stimuli.
Correct Answer: D
Rationale: Flaccid paralysis and unresponsiveness (D) indicate severe brain dysfunction or progression to brain death, worse than decorticate posturing. Purposeful movement (A) or thrashing (C) suggest improvement, and adduction (B) is not a standard indicator.
The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which preprocedure teaching should the nurse implement?
- A. Tell the client to take any routine antiseizure medication prior to the EEG.
- B. Tell the client not to eat anything for eight (8) hours prior to the procedure.
- C. Instruct the client to stay awake for 24 hours prior to the EEG.
- D. Explain to the client that there will be some discomfort during the procedure.
Correct Answer: A
Rationale: Taking routine antiseizure medications (A) ensures therapeutic levels during the EEG, avoiding seizures that could skew results. Fasting (B) is unnecessary, sleep deprivation (C) may be used in specific cases but not routinely, and EEGs are painless (D).
The client diagnosed with Guillain-Barré syndrome is scheduled to receive plasmapheresis treatments. The client’s spouse asks the nurse about the purpose of plasmapheresis. Which explanation is correct?
- A. “Plasmapheresis removes excess fluid from the bloodstream.”
- B. “Plasmapheresis will increase the protein levels in the blood.”
- C. “Plasmapheresis removes circulating antibodies from the blood.”
- D. “Plasmapheresis infuses lipoproteins to restore the myelin sheath.”
Correct Answer: C
Rationale: Aquapheresis or dialysis, not plasmapheresis, will remove excess fluid from the blood. Plasmapheresis does not increase protein levels in the blood. Plasmapheresis is a procedure in which harmful antibodies are removed from the blood. During the procedure, blood is removed from the client, the plasma is separated, and blood cells without the plasma are returned to the client. Plasmapheresis does not involve infusing lipoproteins.