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Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A. The client will take the seizure medication at the same time daily.
- B. The client will remain free of injury if a seizure does occur.
- C. The client will verbalize an understanding of feelings that preempt seizure activity.
- D. The client will post emergency numbers on the refrigerator for ease of obtaining.
Correct Answer: B
Rationale: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
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The nurse is caring for a client with Bell palsy. Which of the following teaching points is a priority in the management of symptoms for this client?
- A. Avoid stimuli that trigger pain.
- B. Use ophthalmic lubricant and protect the eye.
- C. Encourage semiannual dental exams.
- D. Complete the course of antibiotics as prescribed.
Correct Answer: B
Rationale: The VII cranial nerve supplies muscles to the face. In Bell palsy, the eye can be affected which results in incomplete closure and risk for injury. The eye can become dry and irritated unless eye moisturizing drops and ophthalmic ointment is applied. Avoiding stimuli that can trigger pain is specific to tic douloureux (cranial nerve V disorder). Encouraging dental exams is a part of care but not the priority. Antibiotics are not used in the treatment of Bell's palsy because it is thought to be caused by a virus.
The nurse is caring for a client with an inoperable brain tumor. What is a major threat to this client?
- A. Increased intracranial pressure
- B. Decreased intracranial pressure
- C. Hypervolemia
- D. Hypovolemia
Correct Answer: A
Rationale: Nursing management depends on the area of the brain affected, tumor type, treatment approach, and the client's signs and symptoms. If the tumor is inoperable or has expanded despite treatment, increased intracranial pressure (ICP) is a major threat. In this scenario, there are no indications that fluid volume either increasing or decreasing is an issue.
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
- A. Sleep pattern
- B. Mood and affect
- C. Appetite
- D. Muscle spasms
Correct Answer: D
Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.
An older client complains of a constant headache. A physical examination shows papilledema. Based on these symptoms, what condition would the nurse suspect?
- A. Epilepsy
- B. Trigeminal neuralgia
- C. Hypostatic pneumonia
- D. Brain tumor
Correct Answer: D
Rationale: Headache and papilledema are symptoms of a brain tumor, although these symptoms do appear less often in the older adult. Symptoms of epilepsy include seizure activity, whereas symptoms of trigeminal neuralgia would be pain in the jaws or facial muscles. Hypostatic pneumonia develops due to immobility or prolonged bed rest in older clients. The other options are not associated with papilledema or constant headache.
A client adopted at birth recently discovers that Huntington disease is prevalent in the biological family history. The nurse is providing education to the client about the condition. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. In the early stages, people with the disease can participate in most physical activities.
- B. The disease eventually leads to hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements.
- C. Disease-modifying medications for Huntington disease can decrease immune cells and infection protection.
- D. There are specific tests that can be arranged to diagnose whether or not you have the disorder.
- E. Huntington disease is familial; it is not transmitted genetically.
Correct Answer: A,B,C
Rationale: In teaching the client about Huntington disease, the nurse will explain to the client that people with the disease can participate in most physical activities in the early stages, but that the disease eventually causes hallucinations, delusions, impaired judgment, and increased intensity of abnormal movements. The nurse will go on to inform the client that medications for Huntington disease can decrease immune cells and immune protection. There are no specific diagnostic tests for this disorder, and it is transmitted genetically; thus, the nurse will leave out these statements in the teaching.