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The nurse reviews the chart of the client who had a T12 SCI 12 years ago and is receiving baclofen through an intrathecal infusion pump. Which chart information in the exhibit is most important for the nurse to discuss with the HCP?
- A. Assessment findings
- B. Orthostatic hypotension
- C. Laboratory test results
- D. Prescribed medications
Correct Answer: A
Rationale: Exaggerated spasticity, muscle rigidity, and tinnitus are adverse effects of baclofen (Lioresal) that the nurse should discuss with the HCP. The client had a minimal drop in BP from lying to standing and does not have orthostatic hypotension. The WBC and liver enzymes are WNL. The glucose is not significantly elevated and would not warrant notifying the HCP. All prescribed medications are appropriate for the client who has a T12 SCI.
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The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.
Which client statement indicates a need for further teaching about warfarin therapy?
- A. I'll avoid eating large amounts of spinach.'
- B. I'll take my medication at the same time daily.'
- C. I can take ibuprofen for headaches.'
- D. I'll report any unusual bruising.'
Correct Answer: C
Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen instead.
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse has priority?
- A. Assess lung sounds.
- B. Assess the six cardinal fields of gaze.
- C. Assess apical pulse.
- D. Assess level of consciousness.
Correct Answer: D
Rationale: Level of consciousness (D) is the priority assessment in meningitis, as it indicates neurological status and potential complications like increased ICP. Lung sounds (A), eye movements (B), and pulse (C) are secondary.
The nurse is working with clients and their families regarding substance abuse. Which statement is the scientific rationale for teaching the children new coping mechanisms?
- A. The child needs to realize that the parent will be changing behaviors.
- B. The child will need to point out to the parent when the parent is not coping.
- C. Children tend to mimic behaviors of parents when faced with similar situations.
- D. Children need to feel like they are a part of the parent’s recovery.
Correct Answer: C
Rationale: Children often mimic parental behaviors (C), including unhealthy coping mechanisms. Teaching new strategies helps break this cycle. Other options misrepresent the child’s role or focus.