Nokea
The client with muscle weakness asks the nurse during the initial assessment if the symptoms suggest 'Lou Gehrig’s' disease. Which is the nurse’s most appropriate response?
- A. “Muscle weakness can occur from working too much. Avoid thinking the worst.”
- B. “Tell me what has you thinking that you might have Lou Gehrig’s disease.”
- C. “Have you been having trouble remembering things along with this weakness?”
- D. “That is a good question. We will be doing tests to figure out what is going on.”
Correct Answer: B
Rationale: There is no information that the client is working too much. Telling the client to avoid thinking the worst belittles the client’s concern. This is the most appropriate response because it focuses on the client’s concern, encourages verbalization, and solicits more information. ALS (Lou Gehrig’s disease) is a degenerative disease that affects the motor system and does not have a dementia component; thus, a question about memory is inappropriate. This response does not take the client seriously and does not address the client’s concern.
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The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?
- A. Muscle atrophy and flaccidity.
- B. Fatigue and malnutrition.
- C. Slurred speech and dysphagia.
- D. Weakness and paralysis.
Correct Answer: C
Rationale: Slurred speech and dysphagia (C) are early ALS signs due to bulbar muscle involvement. Atrophy/flaccidity (A) and weakness/paralysis (D) occur later, and fatigue/malnutrition (B) are nonspecific.
The nurse is preparing a client diagnosed with rule-out meningitis for a lumbar puncture. Which interventions should the nurse implement? Select all that apply.
- A. Obtain an informed consent from the client or significant other.
- B. Have the client empty the bladder prior to the procedure.
- C. Place the client in a side-lying position with the back arched.
- D. Instruct the client to breathe rapidly and deeply during the procedure.
- E. Explain to the client what to expect during the procedure.
Correct Answer: A,B,C,E
Rationale: Informed consent (A) is required, emptying the bladder (B) ensures comfort, side-lying with back arched (C) facilitates needle insertion, and explaining the procedure (E) reduces anxiety. Rapid breathing (D) is not advised.
Which discharge instruction is most appropriate following the positron emission tomography scan?
- A. Take a mild sedative tonight.
- B. Increase your fluid intake.
- C. Avoid excessive sitting.
- D. Report signs of a fever.
Correct Answer: B
Rationale: Increasing fluid intake helps flush the radioactive tracer used in the PET scan from the body.
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 client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
- A. An oral anticoagulant medication.
- B. A beta blocker medication.
- C. An anti-hyperuricemic medication.
- D. A thrombolytic medication.
Correct Answer: A
Rationale: A TIA in a client with atrial fibrillation is likely due to cardioembolic stroke risk. Oral anticoagulants (A), such as warfarin or direct oral anticoagulants, are prescribed to prevent clot formation. Beta blockers (B) control heart rate, anti-hyperuricemics (C) treat gout, and thrombolytics (D) are used acutely, not for discharge prevention.