Nokea
The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to which of the following cranial nerves?
- A. XII (hypoglossal)
- B. X (vagus)
- C. IX (glossopharyngeal)
- D. VII (facial)
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and larynx, contributing to the gag reflex. Absence of the gag reflex suggests vagus nerve injury. Hypoglossal (XII) controls tongue movement, glossopharyngeal (IX) aids taste and swallowing, and facial (VII) controls facial muscles.
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A client with a history of bipolar disorder is receiving Lithium. The nurse should teach the client to:
- A. Avoid salty foods
- B. Increase fluid intake
- C. Take the medication with meals
- D. Monitor for weight loss
Correct Answer: B
Rationale: Lithium can cause dehydration and toxicity, so increasing fluid intake is essential. Salty foods are not contraindicated, meals are optional, and weight loss is not a primary concern.
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
- A. Depression
- B. Agitation
- C. Psychotic ideation
- D. Anhedonia
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
The nurse instructs a pregnant client (G2P1) to rest in a side-lying position and avoid lying flat on her back. The nurse explains that this is to avoid 'vena caval syndrome,' a condition which:
- A. Occurs when blood pressure increases sharply with changes in position
- B. Results when blood flow from the extremities is blocked or slowed
- C. Is seen mainly in first pregnancies
- D. May require medication if positioning does not help
Correct Answer: B
Rationale: Vena caval syndrome occurs when the gravid uterus compresses the inferior vena cava, slowing blood return from the extremities.
The nurse would expect to include which of the following when planning the management of the client with Lyme disease?
- A. Complete bed rest for 6-8 weeks
- B. Tetracycline treatment
- C. IV amphotericin B
- D. High-protein diet with limited fluids
Correct Answer: B
Rationale: The client is not placed on complete bed rest for 6 weeks. Tetracycline is the treatment of choice for children with Lyme disease who are over the age of 9. IV amphotericin B is the treatment for histoplasmosis. The client is not restricted to a high-protein diet with limited fluids.
The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction is most important?
- A. Low potassium
- B. Low calcium
- C. Low magnesium
- D. Low iron
Correct Answer: A
Rationale: Chronic kidney disease impairs potassium excretion, risking hyperkalemia, which can cause arrhythmias. Low potassium diets are critical. Calcium, magnesium, and iron are less commonly restricted.