Nokea
Which assessment finding is most important to consider before developing the client's care plan?
- A. The client's ability to perform activities of daily living
- B. The client's preferences for and dislikes of various foods
- C. The family members' views about nursing home placement
- D. The client's feelings about giving up independent living
Correct Answer: A
Rationale: The ability to perform ADLs determines the level of assistance needed, guiding the care plan for a client with Parkinson's disease.
You may also like to solve these questions
The nurse and the unlicensed assistive personnel (UAP) are caring for clients on a medical-surgical unit. Which task should not be assigned to the UAP?
- A. Feed the 69-year-old client diagnosed with Parkinson’s disease who is having difficulty swallowing.
- B. Turn and position the 89-year-old client diagnosed with a pressure ulcer secondary to Parkinson’s disease.
- C. Assist the 54-year-old client diagnosed with Parkinson’s disease with toilet-training activities.
- D. Obtain vital signs on a 72-year-old client diagnosed with pneumonia secondary to Parkinson’s disease.
Correct Answer: A
Rationale: Feeding a client with swallowing difficulty (A) requires nursing judgment to assess aspiration risk, so it should not be delegated. Turning/positioning (B), assisting with toileting (C), and vital signs (D) are within UAP scope.
The client diagnosed with breast cancer has developed metastasis to the brain. Which prophylactic measure should the nurse implement?
- A. Institute aspiration precautions.
- B. Refer the client to Reach to Recovery.
- C. Initiate seizure precautions.
- D. Teach the client about mastectomy care.
Correct Answer: C
Rationale: Brain metastases increase seizure risk, so seizure precautions (C) are appropriate. Aspiration precautions (A) are unrelated, Reach to Recovery (B) supports breast cancer recovery, and mastectomy care (D) is not relevant to brain metastases.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
Which nursing intervention is most effective in helping a client with aphasia communicate?
- A. Speak loudly and clearly to the client.
- B. Use simple pictures or a communication board.
- C. Ask the client to write responses to questions.
- D. Encourage the client to repeat words after the nurse.
Correct Answer: B
Rationale: A communication board or pictures aids communication for clients with aphasia by providing visual cues to express needs.
Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.