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The nurse is planning care for a client experiencing agnosia secondary to a cerebrovascular accident. Which collaborative intervention will be included in the plan of care?
- A. Observe the client swallowing for possible aspiration.
- B. Position the client in a semi-Fowler's position when sleeping.
- C. Place a suction setup at the client's bedside during meals.
- D. Refer the client to an occupational therapist for evaluation.
Correct Answer: D
Rationale: Agnosia is the inability to recognize objects, people, or sounds, impacting functional abilities. Referring to an occupational therapist (D) is appropriate to assess and develop strategies for managing agnosia. Swallowing issues (A, C) are related to dysphagia, not agnosia, and semi-Fowler’s position (B) is not specific to agnosia management.
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Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
Which client statement indicates understanding of trigeminal neuralgia management?
- A. I'll apply heat to my face for pain relief.'
- B. I'll avoid chewing on the affected side.'
- C. I'll use a hard toothbrush for oral hygiene.'
- D. I'll wash my face with cold water.'
Correct Answer: B
Rationale: Avoiding chewing on the affected side reduces pain triggers in trigeminal neuralgia.
The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?
- A. Try to help the coworker by confronting the coworker with the nurse’s suspicions.
- B. Tell the coworker that the nurse will give all narcotic medications from now on.
- C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review.
- D. Do nothing until the nurse can prove the coworker has been using drugs.
Correct Answer: C
Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (C) ensures proper investigation while protecting patients. Confronting (A) may escalate, taking over medications (B) doesn’t address the issue, and waiting for proof (D) risks harm.
A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
- A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- B. Discuss the precipitating factors that caused the symptoms.
- C. Schedule for a STAT computed tomography (CT) scan of the head.
- D. Notify the speech pathologist for an emergency consult.
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
- A. A computed tomography (CT).
- B. Blood cultures times two (2).
- C. Electromyogram (EMG).
- D. Lumbar puncture (LP).
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (D) confirms the diagnosis via CSF analysis. CT (A) may precede LP, blood cultures (B) are supportive, and EMG (C) is unrelated.