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What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.
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Which client response depicts normal function of cranial nerve XI?
- A. A client wrinkling the forehead
- B. A client puffing out the cheeks
- C. A client sticking out the tongue
- D. A client shrugging the shoulders
Correct Answer: D
Rationale: Cranial nerve XI (spinal accessory) innervates the trapezius and sternocleidomastoid muscles, enabling shoulder shrugging.
The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
The client has been diagnosed with a cerebrovascular accident (stroke). The client's wife is concerned about her husband's generalized weakness. Which home modification should the nurse suggest to the wife prior to discharge?
- A. Obtain a rubber mat to place under the dinner plate.
- B. Purchase a long-handled bath sponge for showering.
- C. Purchase clothes with Velcro closure devices.
- D. Obtain a raised toilet seat for the client's bathroom.
Correct Answer: B,C,D
Rationale: Generalized weakness post-stroke affects mobility and self-care. A long-handled bath sponge (B) aids bathing, Velcro clothes (C) simplify dressing, and a raised toilet seat (D) facilitates safe toileting. A rubber mat (A) is less relevant to generalized weakness.
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
- A. Note the first thing the client does in the seizure.
- B. Assess the size of the client’s pupils.
- C. Determine if the client is incontinent of urine or stool.
- D. Provide the client with privacy during the seizure.
Correct Answer: A
Rationale: Noting the first action (A) helps identify the seizure type and focus, aiding diagnosis and treatment. Pupil size (B), incontinence (C), and privacy (D) are secondary to ensuring safety and documenting the event.
When the nurse performs a physical assessment, which finding is most indicative of the client's disorder?
- A. Quivering eye movement
- B. Muscle spasms in the lower extremities
- C. Loss of motor function on the affected side
- D. Unilateral facial paralysis
Correct Answer: D
Rationale: Unilateral facial paralysis is the hallmark sign of Bell's palsy, caused by inflammation of cranial nerve VII.