Nokea
The nurse responds to the call light of a patient who has had a cervical diskectomy earlier in the day. The patient states that she is having severe pain that had a sudden onset. What is the nurses most appropriate action?
- A. Palpate the surgical site.
- B. Remove the dressing to assess the surgical site.
- C. Call the surgeon to report the patients pain.
- D. Administer a dose of an NSAID.
Correct Answer: C
Rationale: Sudden severe pain post-diskectomy may indicate graft extrusion, requiring immediate surgical notification. Palpation, dressing removal, or NSAIDs could delay critical intervention.
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A patient with suspected Parkinsons disease is initially being assessed by the nurse. When is the best time to assess for the presence of a tremor?
- A. When the patient is resting
- B. When the patient is ambulating
- C. When the patient is preparing his or her meal tray to eat
- D. When the patient is participating in occupational therapy
Correct Answer: A
Rationale: Parkinson's resting tremor is most evident when extremities are motionless, disappearing with purposeful movement. Assessment during rest is optimal.
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
- A. Use of a bedpan
- B. Use of a raised toilet seat
- C. Sitting quietly on the toilet every 2 hours
- D. Following the outlined bowel program
Correct Answer: B
Rationale: A raised toilet seat aids standing and promotes bowel elimination by improving positioning. Other options do not address both issues effectively.
The nurse is planning the care of a patient who has been recently diagnosed with a cerebellar tumor. Due to the location of this patients tumor, the nurse should implement measures to prevent what complication?
- A. Falls
- B. Audio hallucinations
- C. Respiratory depression
- D. Labile BP
Correct Answer: A
Rationale: Cerebellar tumors cause ataxia and dizziness, increasing fall risk. Hallucinations, respiratory issues, or BP instability are not typical complications.
A patient with amyotrophic lateral sclerosis (ALS) is being visited by the home health nurse who is creating a care plan. What nursing diagnosis is most likely for a patient with this condition?
- A. Chronic confusion
- B. Impaired urinary elimination
- C. Impaired verbal communication
- D. Bowel incontinence
Correct Answer: C
Rationale: ALS causes progressive speech impairment, making impaired verbal communication a primary concern. Cognitive function, bladder, and bowel control are typically preserved.
The nurse is caring for a patient with Huntington disease who has been admitted to the hospital for treatment of malnutrition. What independent nursing action should be implemented in the patients plan of care?
- A. Firmly redirect the patients head when feeding.
- B. Administer phenothiazines after each meal as ordered.
- C. Encourage the patient to keep his or her feeding area clean.
- D. Apply deep, gentle pressure around the patients mouth to aid swallowing.
Correct Answer: D
Rationale: Deep, gentle pressure aids swallowing in Huntington's patients with choreiform movements. Redirecting the head or focusing on cleanliness is inappropriate, and phenothiazines are given before meals.