Nokea
The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?
- A. Insist that the client go to the dining room for meals.
- B. Notify the family of the change in behavior.
- C. Determine if the client wants another roommate.
- D. Complete a Geriatric Depression Scale.
Correct Answer: D
Rationale: Social withdrawal may indicate depression. Completing a Geriatric Depression Scale (D) is the first step to assess this possibility. Forcing dining (A), notifying family (B), or changing roommates (C) are premature without assessment.
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Which should be the nurse's first intervention with the client diagnosed with Bell's palsy?
- A. Explain that this disorder will resolve within a month.
- B. Tell the client to apply heat to the involved side of the face.
- C. Encourage the client to eat a soft diet.
- D. Teach the client to protect the affected eye from injury.
Correct Answer: D
Rationale: Bell’s palsy impairs eye closure, risking corneal damage. Teaching eye protection (D) is the priority. Resolution timeline (A), heat (B), and diet (C) are secondary.
The male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- A. Push aside any furniture.
- B. Place the client on his side.
- C. Assess the client’s vital signs.
- D. Ease the client to the floor.
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (D) prevents injury from falling. Clearing furniture (A) follows, placing on the side (B) is done after the client is safe, and vital signs (C) are assessed post-seizure.
The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
- A. Crackles in the upper lung fields and jugular vein distention.
- B. Muscle weakness in the upper extremities and ptosis.
- C. Exaggerated arm swinging and scanning speech.
- D. Masklike facies and a shuffling gait.
Correct Answer: D
Rationale: Masklike facies and shuffling gait (D) are hallmark signs of Parkinson’s due to bradykinesia and rigidity. Crackles and JVD (A) suggest heart failure, weakness and ptosis (B) indicate myasthenia gravis, and exaggerated arm swinging (C) is opposite to Parkinson’s.
The nurse is teaching the client who is scheduled for an outpatient EEG. Which instruction should the nurse include?
- A. Remove all hairpins before coming in for the EEG test.
- B. Avoid eating or drinking at least 6 hours prior to the test.
- C. Some hair will be removed with a razor to place electrodes.
- D. Have blood drawn for a glucose level 2 hours before the test.
Correct Answer: A
Rationale: In an EEG, electrodes are placed on the scalp over multiple areas of the brain to detect and record patterns of electrical activity. Preparation includes clean hair without any objects in the hair to prevent inaccurate test results. The client should not be NPO since a usual glucose level is important for normal brain functioning. The scalp will not be shaved; the electrodes are applied with paste. There is no indication to have a serum glucose drawn before the test.
When planning for the client's discharge after the diskectomy and spinal fusion, the nurse should include which instructions? Select all that apply.
- A. Avoid twisting or jerking the back.
- B. Wear a soft back brace at all times.
- C. Avoid sitting for long periods during the first week.
- D. Bend from the waist when picking up items from the floor.
- E. Monitor urine output for the first week.
- F. Report lower extremity color changes to the physician.
Correct Answer: A,C,F
Rationale: Avoiding twisting, prolonged sitting, and monitoring for neurological changes (e.g., color changes) promote recovery and prevent complications.