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The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
- A. The client will regain as much neurological function as possible.
- B. The client will have no short-term memory loss.
- C. The client will have improved renal function.
- D. The client will apply hydrocortisone cream daily.
Correct Answer: A
Rationale: The goal for encephalitis is to maximize neurological recovery (A), as inflammation may cause deficits. No memory loss (B) is unrealistic, renal function (C) is unrelated, and hydrocortisone cream (D) is not indicated.
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The client is being discharged following a transsphenoidal hypophysectomy. Which discharge instructions should the nurse teach the client? Select all that apply.
- A. Sleep with the head of the bed elevated.
- B. Keep a humidifier in the room.
- C. Use caution when performing oral care.
- D. Stay on a full liquid diet until seen by the HCP.
- E. Notify the HCP if developing a cold or fever.
Correct Answer: A,C,E
Rationale: Elevating the HOB (A) reduces ICP, cautious oral care (C) prevents surgical site disruption, and reporting infections (E) is critical due to infection risk. Humidifiers (B) are not standard, and a liquid diet (D) is unnecessary unless specified.
The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, 'Why can’t I control these tremors?' Which is the nurse’s best response?
- A. You can control the tremors when you learn to concentrate and focus on the cause.'
- B. The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.'
- C. You have too much acetylcholine in your brain causing the tremors but they will get better with time.'
- D. You are concerned about the tremors? If you want to talk I would like to hear how you feel.'
Correct Answer: B
Rationale: Parkinson’s tremors result from dopamine deficiency (B), and medications like levodopa help. Concentration (A) doesn’t control tremors, acetylcholine imbalance (C) is partial and not time-resolving, and reflection (D) doesn’t answer the question.
The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement?
- A. Refer the child for genetic counseling as soon as possible.
- B. Teach the child to use a warming tray under the food during meals.
- C. Discuss the importance of not abandoning the parent.
- D. Allow the child to talk about the fear of getting the disease.
Correct Answer: D
Rationale: Huntington’s has a 50% genetic risk. Allowing the child to express fears (D) addresses psychosocial needs therapeutically. Genetic counseling (A) is appropriate but secondary, warming trays (B) are irrelevant, and abandonment discussions (C) may guilt-trip.
Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.
Which assessment finding in a client with myasthenia gravis indicates a need for immediate intervention?
- A. Mild diplopia
- B. Difficulty chewing
- C. Weak hand grip
- D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: A low respiratory rate indicates potential respiratory failure in myasthenia gravis, requiring immediate intervention.