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The nurse is monitoring clients for development of a brain abscess. Which client would be the nurse’s lowest priority for monitoring for a brain abscess?
- A. Client with endocarditis
- B. Client with idiopathic epilepsy
- C. Client who had a liver transplant
- D. Client with meningitis
Correct Answer: B
Rationale: The client with endocarditis has an infective process within the body’s circulation and is at risk for septic emboli, which could progress to a brain abscess. The client who has idiopathic epilepsy has the lowest risk of developing a brain abscess because epilepsy from an unknown cause does not have the risk factors of an active infectious process or an impaired immune system. The client with the liver transplant is at risk for brain abscess because immunosuppressant medications depress the immune system. The client with meningitis has an infective process in close proximity to the brain and should be monitored for a brain abscess.
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The nurse is caring for clients on a medical unit. Which client would be most at risk for experiencing a stroke?
- A. A 92-year-old client who is an alcoholic.
- B. A 54-year-old client diagnosed with hepatitis.
- C. A 60-year-old client who has a Greenfield filter.
- D. A 68-year-old client with chronic atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation (D) increases stroke risk due to clot formation. Age (A) is a factor but less specific, hepatitis (B) is unrelated, and Greenfield filters (C) prevent pulmonary embolism, not stroke.
Which nursing intervention is most effective in helping a client with aphasia communicate?
- A. Speak loudly and clearly to the client.
- B. Use simple pictures or a communication board.
- C. Ask the client to write responses to questions.
- D. Encourage the client to repeat words after the nurse.
Correct Answer: B
Rationale: A communication board or pictures aids communication for clients with aphasia by providing visual cues to express needs.
The client diagnosed with ALS asks the nurse, 'I know this disease is going to kill me. What will happen to me in the end?' Which statement by the nurse would be most appropriate?
- A. You are afraid of how you will die?'
- B. Most people with ALS die of respiratory failure.'
- C. Don’t talk like that. You have to stay positive.'
- D. ALS is not a killer. You can live a long life.'
Correct Answer: B
Rationale: Providing factual information about respiratory failure (B) addresses the client’s question honestly while respecting their need for clarity. Reflecting fear (A) is vague, dismissing concerns (C) is untherapeutic, and denying prognosis (D) is inaccurate.
The client is scheduled for an MRI of the brain to confirm a diagnosis of Creutzfeldt-Jakob disease. Which intervention should the nurse implement prior to the procedure?
- A. Determine if the client has claustrophobia.
- B. Obtain a signed informed consent form.
- C. Determine if the client is allergic to egg yolks.
- D. Start an intravenous line in both hands.
Correct Answer: A
Rationale: MRI involves a confined space, so assessing for claustrophobia (A) ensures patient comfort and safety. Consent (B) is required but secondary, egg yolk allergy (C) is irrelevant, and bilateral IVs (D) are unnecessary.
The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement?
- A. Refer the client to the American Spinal Cord Injury Association (ASIA).
- B. Refer the client to the state rehabilitation commission.
- C. Ask the social worker (SW) about applying for disability.
- D. Suggest that the client talk with his significant other about this concern.
Correct Answer: B
Rationale: The state rehabilitation commission (B) provides vocational training and job placement services for individuals with disabilities like SCI. ASIA (A) focuses on research and advocacy, disability application (C) may not address employment goals, and talking with a significant other (D) is not a direct intervention.