Nokea
When the nurse monitors the client's neurologic status, which finding is most suggestive that the client's intracranial pressure is increasing?
- A. Widening pulse pressure
- B. Increased respiratory rate
- C. Elevated temperature
- D. Decreased level of consciousness
Correct Answer: A
Rationale: Widening pulse pressure is a hallmark sign of increasing intracranial pressure, often accompanied by bradycardia (Cushing's triad).
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Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- A. Potential for injury.
- B. Powerlessness.
- C. Disturbed thought processes.
- D. Sexual dysfunction.
Correct Answer: B
Rationale: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (B). Injury (A) is physical, disturbed thought processes (C) relate to cognition, and sexual dysfunction (D) is not directly linked to aphasia.
The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?
- A. The Haemophilus influenzae vaccine.
- B. Antimicrobial chemoprophylaxis.
- C. A 10-day dose pack of corticosteroids.
- D. A gamma globulin injection.
Correct Answer: B
Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (B), such as rifampin, to prevent infection. Vaccines (A) are not for immediate prophylaxis, corticosteroids (C) treat inflammation, and gamma globulin (D) is not indicated.
Which instruction should the nurse include for a client taking phenytoin (Dilantin)?
- A. Brush teeth gently to prevent gum hyperplasia.
- B. Avoid grapefruit juice.
- C. Take the medication with milk.
- D. Increase dietary sodium intake.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia; gentle brushing helps prevent gum complications.
Which should be the nurse's first intervention with the client diagnosed with Bell's palsy?
- A. Explain that this disorder will resolve within a month.
- B. Tell the client to apply heat to the involved side of the face.
- C. Encourage the client to eat a soft diet.
- D. Teach the client to protect the affected eye from injury.
Correct Answer: D
Rationale: Bell’s palsy impairs eye closure, risking corneal damage. Teaching eye protection (D) is the priority. Resolution timeline (A), heat (B), and diet (C) are secondary.