Nokea
When planning care for a client with a stroke, which goal is most appropriate for addressing dysphagia?
- A. The client will swallow soft foods without choking.
- B. The client will eat three full meals daily.
- C. The client will gain 2 pounds in one week.
- D. The client will verbalize hunger before meals.
Correct Answer: A
Rationale: Swallowing soft foods without choking is a realistic and safe goal for managing dysphagia in stroke clients.
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The experienced nurse is instructing the new nurse on subarachnoid hemorrhage. The nurse evaluates that the new nurse understands the information when the new nurse makes which statements? Select all that apply.
- A. “Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm.”
- B. “Subarachnoid hemorrhage occurs during sleep and is noticed when the client awakens.”
- C. “The client experiencing a subarachnoid hemorrhage may state having a severe headache.”
- D. “Tissue plasminogen activator (tPA) should be given to treat a subarachnoid hemorrhage.”
- E. “A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody.”
Correct Answer: A,C,E
Rationale: A subarachnoid hemorrhage is usually caused by rupture of a cerebral aneurysm. Ischemic stroke in older adults, not a subarachnoid hemorrhage, often occurs during sleep when circulation and BP decrease. Irritation of the meninges from bleeding into the subarachnoid spaces causes a severe headache. Thrombolytic therapy with tPA lyses clots and is contraindicated in subarachnoid hemorrhage. Bleeding into the subarachnoid space will cause the CSF to be bloody.
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
- A. A computed tomography (CT).
- B. Blood cultures times two (2).
- C. Electromyogram (EMG).
- D. Lumbar puncture (LP).
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (D) confirms the diagnosis via CSF analysis. CT (A) may precede LP, blood cultures (B) are supportive, and EMG (C) is unrelated.
The nurse is admitting the client for rule-out encephalitis. Which interventions should the nurse assess to support the diagnosis of encephalitis? Select all that apply.
- A. Determine if the client has recently received any immunizations.
- B. Ask the client if he or she has had a cold in the last week.
- C. Check to see if the client has active herpes simplex 1.
- D. Find out if the client has traveled to the Great Lakes region.
- E. Assess for exposure to soil with fungal spores.
Correct Answer: C
Rationale: Encephalitis is often viral, with herpes simplex virus (HSV-1, C) a common cause, supporting the diagnosis. Recent immunizations (A), colds (B), travel (D), and fungal exposure (E) are less directly linked to encephalitis.
The nurse in a long-term care facility has noticed a change in the behavior of one of the clients. The client no longer participates in activities and prefers to stay in his room. Which intervention should the nurse implement first?
- A. Insist that the client go to the dining room for meals.
- B. Notify the family of the change in behavior.
- C. Determine if the client wants another roommate.
- D. Complete a Geriatric Depression Scale.
Correct Answer: D
Rationale: Social withdrawal may indicate depression. Completing a Geriatric Depression Scale (D) is the first step to assess this possibility. Forcing dining (A), notifying family (B), or changing roommates (C) are premature without assessment.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, 'I can’t do anything. Why am I so worthless?' Which statement by the nurse would be most therapeutic?
- A. This must be very hard for you. You’re feeling worthless?'
- B. You shouldn’t feel worthless—you are still alive.'
- C. Why do you feel worthless? You still have the use of your arms.'
- D. If you attended a work rehab program you wouldn’t feel worthless.'
Correct Answer: A
Rationale: Reflecting the client’s feelings (A) validates their emotions and encourages further discussion, promoting therapeutic communication. Other options dismiss feelings (B), challenge the client inappropriately (C), or assume solutions (D).