Nokea
Which activity should the nurse encourage for a client with early Parkinson's disease to improve mobility?
- A. High-intensity aerobic exercise
- B. Daily stretching and balance exercises
- C. Weightlifting three times weekly
- D. Complete bed rest during tremors
Correct Answer: B
Rationale: Stretching and balance exercises improve mobility and reduce fall risk in early Parkinson's disease.
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The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?
- A. Try to help the coworker by confronting the coworker with the nurse’s suspicions.
- B. Tell the coworker that the nurse will give all narcotic medications from now on.
- C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review.
- D. Do nothing until the nurse can prove the coworker has been using drugs.
Correct Answer: C
Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (C) ensures proper investigation while protecting patients. Confronting (A) may escalate, taking over medications (B) doesn’t address the issue, and waiting for proof (D) risks harm.
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.
Which nursing intervention is best during the confusedness?
- A. Reading a newspaper or magazine to the client
- B. Informing the client that confusion is temporary
- C. Withholding verbal communication temporarily
- D. Reorienting the client to place and situation
Correct Answer: D
Rationale: Reorienting the client to place and situation reduces confusion and promotes safety post-craniotomy.
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.
Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply.
- A. Turn the client every two (2) hours.
- B. Encourage the client to increase fluids.
- C. Keep the client in the supine position.
- D. Assess for deep vein thrombosis (DVT).
- E. Assess for any alterations in elimination.
Correct Answer: A,D,E
Rationale: Turning every 2 hours (A) prevents pressure ulcers, assessing DVT (D) addresses immobility risks, and monitoring elimination (E) ensures bowel/bladder function. Increased fluids (B) depend on status, and supine positioning (C) may increase ICP.