Nokea
The husband of a client who is an alcoholic tells the nurse, 'I don’t know what to do. I don’t know how to deal with my wife’s problem.' Which response would be most appropriate by the nurse?
- A. It must be difficult. Maybe you should think about leaving.'
- B. I think you should attend Alcoholics Anonymous.'
- C. I think that Alanon might be very helpful for you.'
- D. You should not enable your wife’s alcoholism.'
Correct Answer: C
Rationale: Alanon (C) supports families of alcoholics, offering coping strategies. Suggesting leaving (A) is judgmental, AA (B) is for alcoholics, and accusing enabling (D) may alienate.
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The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
Which assessment finding in a client with myasthenia gravis indicates a need for immediate intervention?
- A. Mild diplopia
- B. Difficulty chewing
- C. Weak hand grip
- D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: A low respiratory rate indicates potential respiratory failure in myasthenia gravis, requiring immediate intervention.
The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, 'Why can’t I control these tremors?' Which is the nurse’s best response?
- A. You can control the tremors when you learn to concentrate and focus on the cause.'
- B. The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.'
- C. You have too much acetylcholine in your brain causing the tremors but they will get better with time.'
- D. You are concerned about the tremors? If you want to talk I would like to hear how you feel.'
Correct Answer: B
Rationale: Parkinson’s tremors result from dopamine deficiency (B), and medications like levodopa help. Concentration (A) doesn’t control tremors, acetylcholine imbalance (C) is partial and not time-resolving, and reflection (D) doesn’t answer the question.
Which goal is most realistic for a client diagnosed with Parkinson's disease?
- A. To reverse the symptoms and cure the disease
- B. To remove the symptoms of the disease process
- C. To maintain optimal muscle and motor function
- D. To prepare for a progressive terminal disease
Correct Answer: C
Rationale: Maintaining optimal muscle and motor function is realistic, as Parkinson's is progressive but manageable with treatment.