Nokea
The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply.
- A. Determine if the client has recently received any immunizations.
- B. Ask the client if he or she has had a cold in the last week.
- C. Check to see if the client has active herpes simplex 1.
- D. Find out if the client has traveled to the Great Lakes region.
- E. Assess for exposure to soil with fungal spores.
Correct Answer: C
Rationale: Encephalitis is often viral, with herpes simplex virus (HSV-1, C) a common cause, supporting the diagnosis. Recent immunizations (A), colds (B), travel (D), and fungal exposure (E) are less directly linked to encephalitis.
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The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?
- A. The client has cogwheel rigidity when moving the upper extremities.
- B. The client has a decrease in the frequency and severity of tremors.
- C. The client has less facial pain and converses with more facial expression.
- D. The client no longer experiences auras or a severe frontal headache.
Correct Answer: B
Rationale: Cogwheel rigidity, a symptom of PD, is interrupted muscular movement and is not treated with the DBS. DBS is a treatment used for intractable tremors associated with PD. The electrical current interferes with the brain cells initiating the tremors. Severe facial pain is associated with trigeminal neuralgia, not PD rau. The DBS will not affect facial expression. Auras are unusual sensations experienced before a seizure occurs and are not associated with PD.
Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
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.
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
- A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- B. Discuss the precipitating factors that caused the symptoms.
- C. Schedule for a STAT computed tomography (CT) scan of the head.
- D. Notify the speech pathologist for an emergency consult.
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.