Nokea
The nurse is caring for a client newly diagnosed with Parkinson disease. Which topic is most important for the nurse to include in the teaching plan for this client?
- A. Involvement with diversion activities
- B. Enhancement of the immune system
- C. Establishing balanced nutrition
- D. Maintaining a safe environment
Correct Answer: D
Rationale: The primary focus in caring for Parkinson disease is on maintaining a safe environment. Parkinson disease often has a propulsive gait, characterized by a tendency to take increasingly quicker steps while walking and an inability to stop abruptly without losing balance. Prevention of communicable diseases and establishing a balanced nutrition is encouraged with any chronic disorder. Diversional activities can be helpful in times of stress but not a priority.
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The nurse is caring for a client with bacterial meningitis. Which assessment finding(s) is most important in determining nursing care for this client? Select all that apply.
- A. Cloudy cerebral spinal fluid
- B. Pain and stiffness of the extremities
- C. Purpura of hands and feet
- D. Low white blood cell (WBC) count
- E. Low red blood cell (RBC) count
- F. Low antidiuretic hormone (ADH) levels
Correct Answer: A,C
Rationale: The cerebral spinal fluid (CSF) will be cloudy if bacterial meningitis is the causative agent. Purpura indicates a serious complication of bacterial meningitis (disseminated intravascular coagulation) is occurring and may place the client at risk for amputation of those parts. Pain and stiffness of the extremities is not indicative of meningitis. A rise in RBCs, WBCs, and ADH would be expected.
The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased intracranial pressure (ICP). What neurologic sequelae might this client develop?
- A. Damage to the nerves that facilitate vision and hearing
- B. Damage to the vagal nerve
- C. Damage to the olfactory nerve
- D. Damage to the facial nerve
Correct Answer: A
Rationale: Neurologic sequelae in survivors include damage to the cranial nerves that facilitate vision and hearing. Sequelae to meningitis do not include damage to the vagal nerve, the olfactory nerve, or the facial nerve.
The school nurse notes a 6-year-old running across the playground with friends. The child stops in midstride, freezing for a few seconds. Then the child resumes running across the playground. The school nurse suspects what in this child?
- A. An absence seizure
- B. A myoclonic seizure
- C. A partial seizure
- D. A tonic-clonic seizure
Correct Answer: A
Rationale: Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. Both myoclonic and tonic-clonic seizures involve jerking movements.
A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
- A. Dextrose 5% in water (D5W)
- B. Half-normal saline (0.45% NSS)
- C. One-third normal saline (0.33% NSS)
- D. Lactated Ringer's
Correct Answer: D
Rationale: With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
The nurse is caring for a client with mid-to-late stage of an inoperable brain tumor. What teaching is most important for the nurse to do with this client?
- A. Optimizing nutrition
- B. Managing muscle weakness
- C. Explaining hospice care and services
- D. Offering family support groups
Correct Answer: C
Rationale: The nurse explains hospice care and services to clients with brain tumors that no longer are at a stage where they can be cured. Managing muscle weakness and offering family support groups are important, but explaining hospice is the best answer. Optimizing nutrition at this point is not a priority.