Nokea
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
- A. Place an eye patch over the affected eye
- B. Instruct the client to turn their head from side to side
- C. Speak slowly, clearly, and in a deeper voice
- D. Provide the client with ear plugs to promote rest
Correct Answer: B
Rationale: Head turning compensates for the visual field loss in homonymous hemianopia.
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The nurse is caring for a client scheduled for a lumbar puncture (LP). Which of the following clinical manifestations would require follow-up by the nurse before the LP?
- A. Nuchal rigidity
- B. Temperature 101° F (38.3° C)
- C. Petechial rash
- D. Restlessness
Correct Answer: A,B,C
Rationale: Nuchal rigidity, fever, and petechial rash suggest meningitis, which requires urgent evaluation before LP to avoid complications.
The nurse is supervising a graduate nurse implement seizure precautions for a client with epilepsy. Which observation by the nurse requires follow-up?
- A. Pads the side rails of the bed
- B. Lowers the side rails while the client sleeps.
- C. Removes hard and sharp objects from the bed.
- D. Places the client in four point restraints to prevent injury.
- E. Places a fall risk bracelet on the client.
Correct Answer: B,D
Rationale: Lowering side rails and using restraints increase injury risk during seizures and require correction.
The nurse is assessing a client receiving prescribed donepezil. Throughout the duration of therapy, the nurse should monitor the client's
- A. Pulse
- B. Fasting blood glucose
- C. Total cholesterol
- D. Pulse oximetry
Correct Answer: A
Rationale: Donepezil, a cholinesterase inhibitor for Alzheimer's, can cause bradycardia due to increased vagal tone. Monitoring pulse is essential. Blood glucose, cholesterol, and pulse oximetry are not typically affected.
The nurse is assessing a client with suspected autonomic dysreflexia. Which assessment findings would support the diagnosis of autonomic dysreflexia?
- A. Severe headache
- B. Piloerection
- C. Hypotension
- D. Tachycardia
- E. Restlessness
Correct Answer: A,B,E
Rationale: Severe headache, piloerection, and restlessness are signs of autonomic dysreflexia 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.