Nokea
When assisting the client with activities of daily living (ADLs), which approach is best?
- A. Limit the time for performing ADLs to 30 minutes.
- B. Eliminate whatever tasks the client cannot perform.
- C. Let the client rest between activities.
- D. Perform all of the client's ADLs at this time.
Correct Answer: C
Rationale: Allowing rest between activities conserves energy and supports the client's independence during an MS exacerbation.
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The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, 'I don’t know what you mean. What are auras?' Which statement by the nurse would be the best response?
- A. Some people have a warning that the seizure is about to start.'
- B. Auras occur when you are physically and psychologically exhausted.'
- C. You’re concerned that you do not have auras before your seizures?'
- D. Auras usually cause you to be sleepy after you have a seizure.'
Correct Answer: A
Rationale: Auras are sensory warnings preceding a seizure (A), and this response accurately educates the client. Other options misdefine auras (B, D) or fail to address the question (C).
The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?
- A. Assess the client's sense of smell and taste.
- B. Teach the client how to care for the eyes.
- C. Instruct the client to have carbamazepine (Tegretol) levels monitored Multiple Choicely.
- D. Assist the client to identify factors that trigger an attack.
Correct Answer: C
Rationale: Carbamazepine is a primary treatment for trigeminal neuralgia, and Multiple Choice monitoring of levels (C) prevents toxicity and ensures efficacy. Smell/taste (A) are unaffected, eye care (B) is relevant for Bell’s palsy, and triggers (D) are secondary to medication management.
Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis?
- A. History of a cold or gastrointestinal upset in the last month.
- B. Complaints of double vision and drooping eyelids.
- C. Fatigue, progressive muscle weakness, and twitching.
- D. Loss of sensation below the level of the umbilicus.
Correct Answer: C
Rationale: ALS presents with fatigue, progressive muscle weakness, and fasciculations (twitching, C). Recent illness (A) is nonspecific, double vision/ptosis (B) suggests myasthenia gravis, and sensory loss (D) is not typical of ALS.
Which assessment finding in a client post-diskectomy indicates a potential complication?
- A. Mild incisional pain
- B. Numbness in the toes
- C. Clear urine output
- D. Stable vital signs
Correct Answer: B
Rationale: Numbness in the toes may indicate nerve compression or damage, a potential complication requiring further evaluation.