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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Which clinical manifestation will the nurse most likely observe first?
- A. Excessive jerking of the entire body
- B. Sleepiness and disorientation
- C. Loss of consciousness
- D. Absence of deep tendon reflexes
Correct Answer: B
Rationale: In the postictal phase, sleepiness and disorientation are typically observed first as the brain recovers from the seizure.
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.
Which response by the nurse is most appropriate?
- A. Clipping the hair is hospital policy.'
- B. This method is better for you.'
- C. Shaving the head causes microscopic cuts, resulting in risk for infection.'
- D. Surgery could be postponed if bleeding from the scalp occurs.'
Correct Answer: C
Rationale: Clipping avoids microscopic cuts from shaving, reducing infection risk, which is critical for craniotomy.
Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
- A. A 55-year-old African American male.
- B. An 84-year-old Japanese female.
- C. A 67-year-old Caucasian male.
- D. A 39-year-old pregnant female.
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.
- A. Occupational Therapist (OT).
- B. Physical therapist (PT).
- C. Registered dietitian (RD).
- D. Rehabilitation physician.
- E. Social Worker (SW).
- F. Patient care tech (PCT).
Correct Answer: A,B,D,E
Rationale: OT (A) and PT (B) address functional and mobility needs, the physician (D) oversees medical care, and the social worker (E) coordinates resources. Dietitian (C) and PCT (F) are less critical for case conferences.