Nokea
The spouse of a recently retired man tells the nurse, 'All my husband does is sit around and watch television all day long. He is so irritable and moody. I don't want to be around him.' Which action should the nurse implement?
- A. Encourage the wife to leave the client alone.
- B. Tell the wife that he is probably developing Alzheimer's disease.
- C. Recommend that the client see an HCP for an antidepressant medication.
- D. Instruct the wife to buy him some arts and crafts supplies.
Correct Answer: C
Rationale: Irritability and mood changes post-retirement may indicate depression. Recommending an HCP evaluation for antidepressants (C) is appropriate. Leaving alone (A) ignores the issue, Alzheimer’s (B) is premature, and crafts (D) may not address mood.
You may also like to solve these questions
When changing the client's position postoperatively, which nursing action is best?
- A. Raise the client with a mechanical lift.
- B. Logroll the client from side to side.
- C. Have the client flex the knees and lift.
- D. Pull the client's arms and then the legs.
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
- A. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
- B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson’s disease.
- C. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training activities.
- D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
Correct Answer: A
Rationale: Feeding a client with swallowing difficulty (A) requires nursing judgment to assess aspiration risk, so it should not be delegated. Turning/positioning (B), assisting with toileting (C), and vital signs (D) are within UAP scope.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is 'brain dead.' Which data support that the client is brain dead?
- A. When the client's head is turned to the right, the eyes turn to the right.
- B. The electroencephalogram (EEG) has identifiable waveforms.
- C. No eye activity is observed when the cold caloric test is performed.
- D. The client assumes decorticate posturing when painful stimuli are applied.
Correct Answer: C
Rationale: Brain death is confirmed by absent brainstem reflexes, including no eye movement during the cold caloric test (C). Eyes turning with head movement (A) indicates intact reflexes, EEG waveforms (B) suggest brain activity, and decorticate posturing (D) indicates some brain function.
The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply.
- A. Nuchal rigidity
- B. Severe headache
- C. Pill-rolling tremor
- D. Photophobia
- E. Lethargy
Correct Answer: A,B,D,E
Rationale: Irritation of the meninges causes nuchal rigidity (stiff neck). Irritation of the meninges causes severe headache. Pill-rolling tremors are associated with PD. Irritation of the meninges causes photophobia (light irritates the eyes). Lethargy, pathological state of sleepiness or unresponsiveness, indicates a decreased level of consciousness which is associated with meningitis.
The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement?
- A. Refer the child for genetic counseling as soon as possible.
- B. Teach the child to use a warming tray under the food during meals.
- C. Discuss the importance of not abandoning the parent.
- D. Allow the child to talk about the fear of getting the disease.
Correct Answer: D
Rationale: Huntington’s has a 50% genetic risk. Allowing the child to express fears (D) addresses psychosocial needs therapeutically. Genetic counseling (A) is appropriate but secondary, warming trays (B) are irrelevant, and abandonment discussions (C) may guilt-trip.