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The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.
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The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client?
- A. Hospice nurse.
- B. Speech therapist.
- C. Physical therapist.
- D. Occupational therapist.
Correct Answer: B
Rationale: Glossopharyngeal nerve paralysis affects swallowing and speech. A speech therapist (B) is most appropriate to address these deficits. Hospice (A) is for end-of-life care, physical therapy (C) focuses on mobility, and occupational therapy (D) addresses daily activities.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document?
- A. Hemiparesis of the client's left arm and apraxia.
- B. Paralysis of the right side of the body and ataxia.
- C. Homonymous hemianopsia and diplopia.
- D. Impulsive behavior and hostility toward family.
Correct Answer: B
Rationale: A left-sided CVA affects the right side of the body due to the brain's contralateral control. Paralysis or hemiparesis of the right side is a common manifestation, and ataxia (impaired coordination) may also occur. Hemiparesis of the left arm would indicate a right-sided CVA, visual deficits like homonymous hemianopsia are possible but less specific to motor loss, and behavioral changes are not directly related to motor deficits.
Which intervention is most appropriate for a client with Bell's palsy experiencing eye dryness?
- A. Apply warm compresses to the affected eye.
- B. Administer oral antihistamines.
- C. Use artificial tears as prescribed.
- D. Cover the unaffected eye with a patch.
Correct Answer: C
Rationale: Artificial tears prevent corneal damage from eye dryness in Bell's palsy due to incomplete eye closure.
The client has been diagnosed with a brain tumor. Which presenting signs and symptoms help to localize the tumor position?
- A. Widening pulse pressure and bounding pulse.
- B. Diplopia and decreased visual acuity.
- C. Bradykinesia and scanning speech.
- D. Hemiparesis and personality changes.
Correct Answer: B
Rationale: Visual symptoms like diplopia and decreased visual acuity (B) can localize a tumor to areas affecting the optic pathways or occipital lobe. Other options are less specific to tumor location.
When a client is injured during a seizure, which fact is most important to document on the incident (accident) report to reduce the risk of liability?
- A. The client was assigned to a licensed nurse.
- B. The signal cord was within the client's reach.
- C. The client's vital signs had been stable.
- D. The client was last observed reading.
Correct Answer: B
Rationale: Documenting that the signal cord was within reach indicates that safety measures were in place, reducing liability.