Nokea
The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?
- A. A normal temperature will strengthen the client’s immune system.
- B. A hypothermic state may increase the client’s chance of survival.
- C. A normal temperature will decrease the Glasgow Coma Scale score.
- D. Hyperthermia increases the likelihood of a larger area of brain infarct.
Correct Answer: D
Rationale: A normal temperature does not strengthen the immune system. Although hypothermia may increase the client’s chance for survival, the question is asking for the rationale for bringing the temperature to a normal level. Hyperthermia, not a normal temperature, is associated with lower scores on the Glasgow Coma Scale. The nurse should initiate temperature reduction measures because a temperature elevation in the client poststroke can cause an increase in the infarct size. This may be due to the increased oxygen demand with hyperthermia and peripheral vasodilation that decreases cerebral perfusion.
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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.
The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
- A. Perform a complete neurological assessment.
- B. Awaken the client every 30 minutes.
- C. Turn the client to the side and allow the client to sleep.
- D. Interview the client to find out what caused the seizure.
Correct Answer: C
Rationale: Post-seizure, the client is in a postictal phase with lethargy. Turning to the side (C) prevents aspiration and allows safe rest. Neurological assessment (A) can wait until the client is less lethargic, frequent awakening (B) is unnecessary if oriented, and interviewing (D) is not urgent.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
- A. This must be very hard for you. You’re feeling worthless?'
- B. You shouldn’t feel worthless—you are still alive.'
- C. Why do you feel worthless? You still have the use of your arms.'
- D. If you attended a work rehab program you wouldn’t feel worthless.'
Correct Answer: A
Rationale: Reflecting the client’s feelings (A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (B), challenge the client inappropriately (C), or assume solutions (D).
Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
When planning care for a client with a stroke, which goal is most appropriate for addressing dysphagia?
- A. The client will swallow soft foods without choking.
- B. The client will eat three full meals daily.
- C. The client will gain 2 pounds in one week.
- D. The client will verbalize hunger before meals.
Correct Answer: A
Rationale: Swallowing soft foods without choking is a realistic and safe goal for managing dysphagia in stroke clients.