Nokea
The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
- A. Plan to assess the client's cognition after returning to his room.
- B. Confirm that this is an effective technique to help with ambulation.
- C. Reorient the client to his present location and circumstances.
- D. Assist the client to a carpeted area where he can walk more easily.
Correct Answer: B
Rationale: Pretending to step over an object is a known technique to manage freezing in Parkinson's, aiding ambulation.
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A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?
- A. Teach about compliance to reduce blood pressure.
- B. Provide rest periods and portable oxygen.
- C. Maintain continuous monitoring of heart rate and rhythm.
- D. Administer nitroglycerin daily.
Correct Answer: A
Rationale: Reducing blood pressure decreases cardiac workload, preventing cardiomegaly and improving contractility.
The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?
- A. Place protective padding between the client and bed rails.
- B. Provide privacy for the client during the event.
- C. Observe the client's behavior during the event.
- D. Record the client's level of consciousness after the event.
Correct Answer: A
Rationale: Padding prevents injury during a seizure, prioritizing client safety over privacy or observation.
The nurse has determined that a client with trigeminal neuralgia has the nursing problem, 'Imbalanced nutrition, less than body requirements.' Which cause is most likely contributing to the problem?
- A. Fatigue.
- B. Pain when eating.
- C. Nausea.
- D. Altered taste sensation.
Correct Answer: B
Rationale: Severe facial pain from trigeminal neuralgia deters eating, leading to imbalanced nutrition.
A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?
- A. Implement seizure precautions.
- B. Begin straining all urine.
- C. Administer a PRN dose of a laxative.
- D. Initiate cardiac telemetry.
Correct Answer: B
Rationale: Straining urine checks for kidney stones, likely causing flank pain in hyperparathyroidism, prioritizing over other interventions.
The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take?
- A. Prepare to administer a glucose, then insulin, then potassium infusion.
- B. Inform the healthcare provider of the need for potassium replacement.
- C. Instruct the client to Increase dally Intake of potassium rich foods.
- D. Change the plan of care to Include hourly urinary output measurements.
Correct Answer: B
Rationale: Severe hypokalemia requires immediate potassium replacement, necessitating healthcare provider notification, rather than dietary changes or monitoring alone.