Nokea
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.
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Which type of precautions should the nurse implement for the client diagnosed with septic meningitis?
- A. Standard Precautions.
- B. Airborne Precautions.
- C. Contact Precautions.
- D. Droplet Precautions.
Correct Answer: D
Rationale: Meningococcal meningitis is transmitted via respiratory droplets, requiring Droplet Precautions (D) in addition to Standard Precautions. Airborne (B) and Contact (C) are not indicated.
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.
Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
The client is being admitted to rule out a brain tumor. Which classic triad of symptoms supports a diagnosis of brain tumor?
- A. Nervousness, metastasis to the lungs, and seizures.
- B. Headache, vomiting, and papilledema.
- C. Hypotension, tachycardia, and tachypnea.
- D. Abrupt loss of motor function, diarrhea, and changes in taste.
Correct Answer: B
Rationale: The classic triad for brain tumors is headache, vomiting, and papilledema (B), due to increased ICP. Other options include unrelated or less specific symptoms.
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2°F, P 98, R 24, and BP 84/40. Which action should the nurse implement?
- A. Notify the health-care provider as soon as possible (ASAP).
- B. Calm the client down by talking therapeutically.
- C. Increase the IV rate by 50 mL/hour.
- D. Lower the head of the bed immediately.
Correct Answer: D
Rationale: Light-headedness and low BP (84/40) in T1 SCI suggest orthostatic hypotension or neurogenic shock. Lowering the HOB (D) restores cerebral perfusion. Notifying the provider (A) or increasing IV rate (C) follows, and talking therapeutically (B) does not address the urgent issue.