Nokea
The nurse is preparing to teach a client who was recently diagnosed with Meniere's disease. To help the client reduce the incidence of attacks, the nurse should recommend that the client do which of the following?
- A. Irrigate their ears with sterile water.
- B. Reduce dietary sodium intake.
- C. Do not use earbuds or headphones.
- D. Speak with limited inflections.
Correct Answer: B
Rationale: Reducing sodium intake helps manage fluid balance in Meniere's disease, reducing attack frequency.
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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 performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus?
- A. Rubor of the feet and ankles when the leg is in the dependent position
- B. Rapid, rhythmic muscle contractions
- C. Popping or clicking of the knee joint with movement
- D. Audible cracking and palpable grating with movement of the joints
Correct Answer: B
Rationale: Clonus is characterized by rapid, rhythmic muscle contractions, often seen in neurological disorders.
The nurse is caring for an elderly home health client experiencing a sudden onset of delirium. Which of the following should the home health nurse assess first?
- A. Drug intoxication
- B. Increased hearing loss
- C. Cancer metastases
- D. Congestive heart failure
Correct Answer: A
Rationale: Drug intoxication is a common and reversible cause of delirium in the elderly.
The nurse is performing a follow-up assessment on a client who was prescribed carbidopa/levodopa. Which assessment finding would indicate a therapeutic finding from this medication?
- A. Decrease in tremors
- B. Improvement in the excessive drooling
- C. Reduction in seizure activity
- D. Improvement in muscle spasticity
Correct Answer: A
Rationale: Carbidopa/levodopa is used for Parkinson's disease, and a decrease in tremors indicates therapeutic efficacy.
The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
- A. Administer sublingual nitroglycerin.
- B. Elevate the head of the bed.
- C. Obtain a residual volume reading with a bladder scan.
- D. Perform a digital examination to assess for the presence of stool.
Correct Answer: B
Rationale: Elevating the head of the bed reduces blood pressure in autonomic dysreflexia.