Nokea
The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. If I experience double-vision, I should put an eye patch on both eyes for a few hours.
- B. Planning my activities should help manage the fatigue.
- C. I should plan to take a hot bath for my muscle spasms.
- D. This disease may cause me to have an increased sensitivity to pain.
Correct Answer: B
Rationale: Planning activities helps manage fatigue, a common symptom in multiple sclerosis. Hot baths can worsen symptoms, and eye patches are used for one eye, not both.
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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 3 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.
The client is at highest risk for developing …………………..
- A. Bacterial meningitis
- B. Influenza
- C. Benzodiazepine toxicity
Correct Answer: A
Rationale: Symptoms (fever, neck stiffness, altered mental status) strongly suggest bacterial meningitis.
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 assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
- A. Client reports a decreased smell
- B. No bowel movement in two days
- C. Foul-smelling breath
- D. Hourly urine output of 125 mL
Correct Answer: D
Rationale: High urine output suggests diabetes insipidus, a serious complication post-hypophysectomy.
The nurse is teaching a client with Parkinson's disease about dietary considerations. The nurse understands that this client is at highest risk for
- A. Constipation and drooling
- B. Drooling and a loss of appetite
- C. Loose stools and choking
- D. Dysphagia and aspiration
Correct Answer: D
Rationale: Parkinson's disease increases risk for dysphagia and aspiration due to impaired swallowing.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
- A. Peripheral artery disease
- B. Accelerated hypertension
- C. Migraine headache
- D. Angina
Correct Answer: C
Rationale: Sumatriptan is a triptan specifically used to treat migraine headaches by constricting blood vessels and reducing inflammation. It is not used for peripheral artery disease, hypertension, or angina.