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Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
- A. The client has flaccid paralysis.
- B. The client has purposeful movement.
- C. The client has decerebrate posturing with painful stimuli.
- D. The client does not move the extremities.
Correct Answer: B
Rationale: Purposeful movement (B) indicates improved brain function compared to decorticate posturing. Flaccid paralysis (A) or decerebrate posturing (C) suggest worsening, and no movement (D) is not an improvement.
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The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?
- A. There will be fewer side effects with this combination than with carbidopa alone.
- B. Dopamine D requires the presence of both of these medications to work.
- C. Carbidopa makes more levodopa available to the brain.
- D. Carbidopa crosses the blood-brain barrier to treat Parkinson’s disease.
Correct Answer: C
Rationale: Carbidopa inhibits peripheral breakdown of levodopa, allowing more levodopa to cross the blood-brain barrier and convert to dopamine (C). This enhances efficacy and reduces side effects. Other options are incorrect.
The nurse is assessing a client experiencing motor loss as a result of a left-sided cerebrovascular accident (CVA). Which clinical manifestation would the nurse document?
- A. Hemiparesis of the client's left arm and apraxia.
- B. Paralysis of the right side of the body and ataxia.
- C. Homonymous hemianopsia and diplopia.
- D. Impulsive behavior and hostility toward family.
Correct Answer: B
Rationale: A left-sided CVA affects the right side of the body due to the brain's contralateral control. Paralysis or hemiparesis of the right side is a common manifestation, and ataxia (impaired coordination) may also occur. Hemiparesis of the left arm would indicate a right-sided CVA, visual deficits like homonymous hemianopsia are possible but less specific to motor loss, and behavioral changes are not directly related to motor deficits.
When planning a bowel retraining program for a client with a spinal cord injury, which nursing intervention is most appropriate?
- A. Administering a stool softener twice per week
- B. Encouraging the client to consume a high-fiber diet
- C. Having the client drink two glasses of water every morning
- D. Teaching the client to self-administer daily enemas
Correct Answer: B
Rationale: A high-fiber diet promotes regular bowel movements, which is essential for bowel retraining in spinal cord injury clients.
The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first?
- A. Schedule a STAT Magnetic Resonance Imaging of the brain.
- B. Call a Code STROKE.
- C. Notify the health-care provider (HCP).
- D. Have the client swallow a glass of water.
Correct Answer: B
Rationale: Symptoms suggest an acute stroke, requiring immediate activation of a Code STROKE (B) to expedite diagnosis and treatment. MRI (A), notifying HCP (C), and swallowing tests (D) follow protocol activation.
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak?
- A. Clients recently discharged from the hospital.
- B. Residents of a college dormitory.
- C. Individuals who visit a third world country.
- D. Employees in a high-rise office building.
Correct Answer: B
Rationale: College dormitory residents (B) are at high risk for meningococcal meningitis due to close living conditions and shared spaces. Hospital discharges (A), travel (C), or office workers (D) are less specific risks.