Nokea
The nurse is caring for the client diagnosed with West Nile virus. Which assessment data would require immediate intervention from the nurse?
- A. The vital signs are documented as T 100.2°F, P 80, R 18, and BP 136/78.
- B. The client complains of generalized body aches and pains.
- C. Positive results are reported from the enzyme-linked immunosorbent assay (ELISA).
- D. The client becomes lethargic and is difficult to arouse using verbal stimuli.
Correct Answer: D
Rationale: Lethargy and difficulty arousing (D) indicate neurological deterioration, requiring immediate intervention. Mild fever (A), body aches (B), and positive ELISA (C) are expected.
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The client with a history of migraine headaches comes to the emergency department complaining of a migraine headache. Which collaborative treatment should the nurse anticipate?
- A. Administer an injection of sumatriptan (Imitrex), a triptan.
- B. Prepare for a computed tomography (CT) of the head.
- C. Place the client in a quiet room with the lights off.
- D. Administer propranolol (Inderal), a beta blocker.
Correct Answer: A
Rationale: Sumatriptan (A) is a first-line treatment for acute migraines. CT (B) is for atypical cases, quiet room (C) is supportive, and propranolol (D) is for prophylaxis.
The client is diagnosed with Huntington's chorea. Which interventions should the nurse implement with the family? Select all that apply.
- A. Refer to the Huntington's Chorea Foundation.
- B. Explain the need for the client to wear football padding.
- C. Discuss how to cope with the client's messiness.
- D. Provide three (3) meals a day and no between-meal snacks.
- E. Teach the family how to perform chest percussion.
Correct Answer: A,C
Rationale: Referring to the Huntington’s Disease Society (A) provides support and resources. Discussing coping with messiness (C) addresses chorea-related coordination issues. Football padding (B) is inappropriate, meal restrictions (D) are unnecessary, and chest percussion (E) is unrelated.
The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statements by the nurse will be helpful to the client? Select all that apply.
- A. “You need to continue to use contraceptives if you do not wish to have children.”
- B. “Unfortunately, your injury prevents you from being able to conceive children.”
- C. “Because feeling is affected, it is not likely that you will be able to deliver a baby.”
- D. “Sexual intercourse is generally prohibited because it can worsen your condition.”
- E. “You can engage in sexual intimacy, but you may not be able to feel an orgasm.”
Correct Answer: A,E
Rationale: Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. The client with an incomplete T6 SCI is able to get pregnant. Although the client may not feel the onset of labor, she may still be able to deliver the baby vaginally or via cesarean section. Sexual intercourse is allowable and would not worsen the client’s condition. The female may not be able to feel an orgasm. The client may not be able to feel an orgasm after an incomplete T6 SCI.
The public health nurse is discussing St. Louis encephalitis with a group in the community. Which instruction should the nurse provide to help prevent an outbreak?
- A. Yearly vaccinations for the disease.
- B. Advise that the city should spray for mosquitoes.
- C. The use of gloves when gardening.
- D. Not going out at night.
Correct Answer: B
Rationale: St. Louis encephalitis is mosquito-borne. Mosquito spraying (B) reduces vector populations. No vaccine exists (A), gloves (C) are irrelevant, and night avoidance (D) is less effective.
The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as 'high risk for immobility complications.' Which intervention would be included in the plan of care?
- A. Position the client with the head of the bed elevated at intervals.
- B. Perform active range-of-motion (ROM) exercises every four (4) hours.
- C. Turn the client every shift and massage bony prominences.
- D. Explain all procedures to the client before performing them.
Correct Answer: A
Rationale: For a comatose patient, preventing immobility complications like pressure ulcers and contractures is key. Elevating the HOB at intervals (A) promotes circulation and reduces pressure. Active ROM (B) is not possible in coma, turning every shift (C) is too infrequent, and explaining procedures (D) is less relevant.