Nokea
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, 'I don’t know what you mean. What are auras?' Which statement by the nurse would be the best response?
- A. Some people have a warning that the seizure is about to start.'
- B. Auras occur when you are physically and psychologically exhausted.'
- C. You’re concerned that you do not have auras before your seizures?'
- D. Auras usually cause you to be sleepy after you have a seizure.'
Correct Answer: A
Rationale: Auras are sensory warnings preceding a seizure (A), and this response accurately educates the client. Other options misdefine auras (B, D) or fail to address the question (C).
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Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis?
- A. History of a cold or gastrointestinal upset in the last month.
- B. Complaints of double vision and drooping eyelids.
- C. Fatigue, progressive muscle weakness, and twitching.
- D. Loss of sensation below the level of the umbilicus.
Correct Answer: C
Rationale: ALS presents with fatigue, progressive muscle weakness, and fasciculations (twitching, C). Recent illness (A) is nonspecific, double vision/ptosis (B) suggests myasthenia gravis, and sensory loss (D) is not typical of ALS.
The public health department nurse is preparing a lecture on prevention of West Nile virus. Which information should the nurse include?
- A. Change water daily in pet dishes and birdbaths.
- B. Wear thick, dark clothing when outside to avoid bites.
- C. Apply insect repellent over face and arms only.
- D. Explain that mosquitoes are more prevalent in the morning.
Correct Answer: A
Rationale: Changing water daily in pet dishes and birdbaths (A) prevents mosquito breeding, reducing West Nile virus risk. Thick clothing (B) should be light-colored, repellent (C) should cover all exposed areas, and mosquitoes are more active at dusk (D).
The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan?
- A. Ensure the traction weight hangs freely
- B. Remove the vest from the device at bedtime
- C. Cleanse sites where the pins enter the skull
- D. Screw the pins in the skull daily to tighten.
Correct Answer: C
Rationale: Neither traction nor weights are part of the halo device. The halo external fixation device includes a vest that is worn continuously and should not be removed. The neurosurgeon will discontinue it when the injury has stabilized and sufficient healing has occurred. A halo external fixation device is a static device that consists of a “halo” that is screwed into the skull by four pins. It is attached to a vest that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pin sites. The nurse should not tighten the pins. These are secured in the skull to maintain alignment of the cervical vertebrae. If loose, the nurse should contact the HCP for tightening.
The nurse caring for a client diagnosed with Parkinson’s disease writes a problem of 'impaired nutrition.' Which nursing intervention would be included in the plan of care?
- A. Consult the occupational therapist for adaptive appliances for eating.
- B. Request a low-fat, low-sodium diet from the dietary department.
- C. Provide three (3) meals per day that include nuts and whole-grain breads.
- D. Offer six (6) meals per day with a soft consistency.
Correct Answer: A
Rationale: PD can impair fine motor skills, making eating difficult. Consulting an occupational therapist (A) for adaptive appliances supports nutritional intake. Low-fat diets (B) are not specific, nuts/breads (C) may be hard to chew, and six soft meals (D) may not address motor issues.
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- A. Teach Credé’s maneuver to the client needing to void.
- B. Administer the tube feeding to the client who is quadriplegic.
- C. Assist with bowel training by placing the client on the bedside commode.
- D. Observe the client demonstrating self-catheterization technique.
Correct Answer: C
Rationale: Assisting with bowel training by placing the client on a commode (C) is within the UAP’s scope, involving physical assistance. Teaching (A), administering tube feedings (B), and observing techniques (D) require nursing judgment and are not delegable.