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The nurse assessed the client newly diagnosed with MG. Which finding should the nurse recognize as being unrelated to the diagnosis?
- A. Drooping eyelids
- B. Slurred speech
- C. Weak lower extremities
- D. Circumoral tingling
Correct Answer: D
Rationale: Ptosis (drooping eyelids) is a sign of muscle weakness often seen with MG. If the muscles involved with speech are weak in the client with MG, the client may exhibit slurred speech. Clients with MG may demonstrate weakness in the lower extremities. Numbness around the mouth is not associated with muscle weakness but could be indicative of a calcium deficiency or some other problem.
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A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
- A. Administer a stool softener bid.
- B. Encourage the client to cough hourly.
- C. Monitor neurological status every shift.
- D. Maintain the dopamine drip to keep BP at 160/90.
Correct Answer: A
Rationale: Post-craniotomy for subarachnoid hemorrhage, preventing increased intracranial pressure is critical. A stool softener (A) prevents straining, which could raise ICP. Coughing (B) increases ICP, neurological checks (C) should be more frequent (e.g., hourly), and dopamine to maintain high BP (D) risks re-bleeding.
Which client response depicts normal function of cranial nerve XI?
- A. A client wrinkling the forehead
- B. A client puffing out the cheeks
- C. A client sticking out the tongue
- D. A client shrugging the shoulders
Correct Answer: D
Rationale: Cranial nerve XI (spinal accessory) innervates the trapezius and sternocleidomastoid muscles, enabling shoulder shrugging.
The 29-year-old client who was employed as a forklift operator sustains a traumatic brain injury (TBI) secondary to a motor-vehicle accident. The client is being discharged from the rehabilitation unit after three (3) months and has cognitive deficits. Which goal would be most realistic for this client?
- A. The client will return to work within six (6) months.
- B. The client is able to focus and stay on task for 10 minutes.
- C. The client will be able to dress self without assistance.
- D. The client will regain bowel and bladder control.
Correct Answer: B
Rationale: Cognitive deficits post-TBI may limit complex tasks. Focusing for 10 minutes (B) is a realistic short-term goal to build cognitive endurance. Returning to work (A) may be unrealistic within 6 months, dressing independently (C) requires motor and cognitive skills, and bowel/bladder control (D) may be affected by physical deficits.
The nurse educator is presenting an in-service on seizures. Which disease process is the leading cause of seizures in the elderly?
- A. Alzheimer’s disease.
- B. Parkinson’s disease (PD).
- C. Cerebral Vascular Accident (CVA, stroke).
- D. Brain atrophy due to aging.
Correct Answer: C
Rationale: Stroke (CVA, C) is the leading cause of seizures in the elderly due to brain tissue damage. Alzheimer’s (A) and Parkinson’s (B) may cause seizures but are less common, and brain atrophy (D) is not a primary cause.
Of the following nursing observations, which is most important to discuss the client's condition?
- A. The client has a chronic cough.
- B. The client is becoming jittery.
- C. The client's skin is warm and clammy.
- D. The client develops diarrhea.
Correct Answer: A
Rationale: A chronic cough increases intrathoracic pressure, which can elevate intracranial pressure and risk aneurysm rupture.