Nokea
The nurse is performing an assessment on a client with Wernicke's aphasia. Which client finding would be consistent with this diagnosis?
- A. Loss of ability to execute or carry out skilled movements.
- B. Cannot express any words.
- C. Cannot swallow liquids.
- D. Speaks with normal fluency and prosody.
Correct Answer: D
Rationale: Wernicke's aphasia is characterized by fluent but nonsensical speech with preserved fluency and prosody.
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The nurse cares for geriatric clients. The nurse knows which of the following is the leading cause of cognitive impairment in old age?
- A. Stroke
- B. Malnutrition
- C. Alzheimer's disease
- D. Loss of cardiac reserve
Correct Answer: C
Rationale: Alzheimer's disease is the most common cause of cognitive impairment in the elderly.
The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
- A. Cocaine intoxication
- B. Respiratory acidosis
- C. Tonic-clonic seizures
- D. Aggression
Correct Answer: B
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.
In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia?
- A. Hypotension
- B. Sudden headache
- C. Flushed face
- D. Nasal congestion
- E. Profuse sweating above the level of the injury
Correct Answer: B,C,D,E
Rationale: Autonomic dysreflexia causes headache, flushing, nasal congestion, and sweating above the injury level due to sympathetic overactivity.
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 1 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Which of the following assessment findings require immediate follow-up?
- A. Neurological assessment findings
- B. Pulse and temperature
- C. Gastrointestinal assessment findings
- D. Influenza vaccination status
- E. Daily smoking habit
- F. Blood pressure and pulse oximetry reading
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.