Nokea
The nurse is caring for an older adult with advanced dementia. The client asks about her deceased sister, 'When will my sister come to visit me this afternoon?' Which is the best response from the nurse?
- A. This is so sad. I'm sorry to tell you but your sister died last year.'
- B. She won't be coming to visit today.'
- C. I understand you want her to visit you. Where did you and your sister grow up?'
- D. Wait and see if she comes to visit today.'
Correct Answer: C
Rationale: Redirecting the conversation compassionately avoids distress and engages the client with dementia.
You may also like to solve these questions
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 1 of 6
History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
The nurse is assessing the client with a persistent headache. Which two (2) findings from the client's history and physical examination are most concerning and require immediate intervention?
- A. Headache described as throbbing and located behind the left eye
- B. Visual disturbances, including flashes of light and blurred vision
- C. Confusion and difficulty speaking
- D. Persistent nausea despite normoactive bowel sounds
- E. Use of escitalopram and buspirone for generalized anxiety disorder
- F. Right arm weakness
Correct Answer: C,F
Rationale: Confusion, difficulty speaking, and right arm weakness suggest a possible stroke or other serious neurological condition, requiring immediate intervention. Throbbing headache, visual disturbances, nausea, and medication use are less urgent.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 6 of 6
• History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
• Diagnostics Test Results
Head Computed Tomography (CT) scan
1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes.
• Nurses' Notes
1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.
The nurse makes a note in the nurses' notes and reviews the diagnostic test results. Complete the sentence below from the list of options. The client is most likely experiencing--------------------as evidenced by------------------and-----------------
- A. transient ischemic attack
- B. somatic anxiety symptoms
- C. ischemic stroke
- D. migraine headache
- E. photophobia
- F. throbbing headache
Correct Answer: D,E,F
Rationale: The client's presentation is most consistent with a migraine headache. Given the client's history of recurrent migraines, the persistent throbbing pain localized behind the left eye, nausea, photophobia, and phonophobia, the symptoms strongly align with a migraine rather than an alternative neurological or psychiatric condition.
While the client’s transient confusion and difficulty speaking raise concerns for a transient ischemic attack (TIA) or stroke, a TIA typically resolves within 30 to 60 minutes and does not persist beyond 24 hours. A TIA is highly unlikely since the client’s headache has been ongoing for 48 hours. Furthermore, ischemic strokes typically present with persistent focal neurological deficits, which are absent on the client's neurological exam.
Although the client has a documented history of generalized anxiety and panic disorder, panic attacks do not last for extended durations and generally resolve within minutes to an hour. Additionally, panic-related somatic symptoms typically include shortness of breath, dizziness, chest discomfort, and a sense of impending doom, rather than the prolonged headache, visual disturbances, and nausea seen in this case.
The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition?
- A. Multiple Sclerosis
- B. Parkinson disease
- C. Schizophrenia
- D. Guillain-Barré syndrome
Correct Answer: B
Rationale: Ropinirole is a dopamine agonist used to treat Parkinson's disease by improving motor symptoms. It is not indicated for Multiple Sclerosis, Schizophrenia, or Guillain-Barré syndrome, which involve different pathophysiology and treatments.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Presbycusis
- B. Ototoxic substance
- C. Foreign body
- D. Exposure to loud noise
- E. Edema
Correct Answer: A,B,D
Rationale: Presbycusis, ototoxic substances, and loud noise exposure cause sensorineural hearing loss by damaging the inner ear or auditory nerve.
The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following?
- A. Apraxia
- B. Agraphia
- C. Agnosia
- D. Aphasia
Correct Answer: C
Rationale: Agnosia is the inability to recognize familiar objects or people, common in dementia.