Nokea
When the nursing team discusses the client's plan of care, which has the highest priority?
- A. Teaching the client about prevention of skin breakdown
- B. Strengthening the client's upper body muscles
- C. Confronting the client's denial of the prognosis
- D. Letting the client verbalize about the accident
Correct Answer: A
Rationale: Preventing skin breakdown is the highest priority to avoid complications like pressure ulcers in clients with spinal cord injuries.
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Which problem is the highest priority for the client diagnosed with West Nile virus?
- A. Alteration in body temperature.
- B. Altered tissue perfusion.
- C. Fluid volume excess.
- D. Altered skin integrity.
Correct Answer: A
Rationale: Fever (alteration in body temperature, A) is a primary symptom of West Nile virus, requiring priority management to prevent complications. Perfusion (B), fluid excess (C), and skin integrity (D) are less immediate.
The client diagnosed with ALS asks the nurse, 'I know this disease is going to kill me. What will happen to me in the end?' Which statement by the nurse would be most appropriate?
- A. You are afraid of how you will die?'
- B. Most people with ALS die of respiratory failure.'
- C. Don’t talk like that. You have to stay positive.'
- D. ALS is not a killer. You can live a long life.'
Correct Answer: B
Rationale: Providing factual information about respiratory failure (B) addresses the client’s question honestly while respecting their need for clarity. Reflecting fear (A) is vague, dismissing concerns (C) is untherapeutic, and denying prognosis (D) is inaccurate.
A 20-year-old female client who tried lysergic acid diethylamide (LSD) as a teen tells the nurse that she has bad dreams that make her want to kill herself. Which is the explanation for this occurrence?
- A. These occurrences are referred to as 'holdover reactions' to the drug.
- B. These are flashbacks to a time when the client had a 'bad trip.'
- C. The drug is still in the client’s body and causing these reactions.
- D. The client is suicidal and should be on one-to-one precautions.
Correct Answer: B
Rationale: LSD can cause flashbacks (B), where users re-experience effects like bad dreams years later, especially from a 'bad trip.' Holdover reactions (A) is not a term, LSD is not stored long-term (C), and suicidal ideation (D) requires assessment but is not the explanation.
The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach?
- A. There will be a large turban dressing around the skull after surgery.
- B. The client will not be able to eat for four (4) or five (5) days postop.
- C. The client should not blow the nose for two (2) weeks after surgery.
- D. The client will have to lie flat for 24 hours following the surgery.
Correct Answer: C
Rationale: Blowing the nose (C) risks disrupting the surgical site and causing CSF leaks after transsphenoidal surgery. Turban dressings (A) are not used, eating resumes sooner (B), and flat positioning (D) is not required.
The client diagnosed with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which intervention should the nurse implement prior to administering the medication?
- A. Discuss how to prevent orthostatic hypotension.
- B. Take the client's apical pulse for one (1) full minute.
- C. Inform the client that this medication is for short-term use.
- D. Tell the client to take the medication on an empty stomach.
Correct Answer: A
Rationale: Carbidopa/levodopa can cause orthostatic hypotension. Discussing prevention (A) ensures safety. Pulse (B) is not routine, the medication is long-term (C), and it can be taken with food (D) to reduce nausea.