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The client with end-stage ALS requires a gastrostomy tube feeding. Which finding would require the nurse to hold a bolus tube feeding?
- A. A residual of 125 mL.
- B. The abdomen is soft.
- C. Three episodes of diarrhea.
- D. The potassium level is 3.4 mEq/L.
Correct Answer: A
Rationale: A gastric residual of 125 mL (A) indicates delayed gastric emptying, requiring the feeding to be held to prevent aspiration. Soft abdomen (B) is normal, diarrhea (C) requires monitoring but not holding, and low potassium (D) is unrelated.
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The rehabilitation nurse caring for the client with an Lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement?
- A. Keep oxygen via nasal cannula on at all times.
- B. Administer low-dose subcutaneous anticoagulants.
- C. Perform active lower extremity ROM exercises.
- D. Refer to a speech therapist for ventilator-assisted speech.
Correct Answer: B
Rationale: Lumbar SCI affects lower extremities, increasing DVT risk. Low-dose anticoagulants (B) prevent thromboembolism. Oxygen (A) is unnecessary without respiratory issues, active ROM (C) is not feasible due to paralysis, and speech therapy (D) is irrelevant.
The client is diagnosed with Creutzfeldt-Jakob disease. Which referral would be the most appropriate?
- A. Alzheimer's Association.
- B. Creutzfeldt-Jakob Disease Foundation.
- C. Hospice care.
- D. A neurosurgeon.
Correct Answer: B
Rationale: The Creutzfeldt-Jakob Disease Foundation (B) provides specialized support and resources. Alzheimer’s Association (A) is unrelated, hospice (C) may be premature, and neurosurgery (D) is not typically indicated.
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 home care suggestion is best for promoting the mobility of the client with a spinal cord injury?
- A. Rent or buy a conventional hospital bed.
- B. Build a wheelchair ramp to the door.
- C. Apply for a handicapped parking sticker.
- D. Provide a raised toilet seat with grab bars.
Correct Answer: B
Rationale: A wheelchair ramp enhances home accessibility, significantly improving mobility for a client with a spinal cord injury.
Which medication should the nurse administer first during a prolonged seizure?
- A. Phenytoin (Dilantin) IV
- B. Lorazepam (Ativan) IV
- C. Levetiracetam (Keppra) oral
- D. Carbamazepine (Tegretol) oral
Correct Answer: B
Rationale: Lorazepam IV is the first-line treatment for status epilepticus to rapidly stop seizure activity.