Nokea
Which client statement indicates a need for further teaching about meningitis precautions?
- A. I'll wear a mask when visitors come.'
- B. My family should wash their hands frequently.'
- C. I can share my water bottle with my spouse.'
- D. I'll stay in my room to avoid spreading germs.'
Correct Answer: C
Rationale: Sharing a water bottle can transmit meningitis, indicating a misunderstanding of droplet precaution protocols.
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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.
Which rationale explains the transmission of the West Nile virus?
- A. Transmission occurs through exchange of body fluids when sneezing and coughing.
- B. Transmission occurs only through mosquito bites and not between humans.
- C. Transmission can occur from human to human in blood products and breast milk.
- D. Transmission occurs with direct contact from the maculopapular rash drainage.
Correct Answer: B
Rationale: West Nile virus is primarily transmitted via mosquito bites (B), not human-to-human contact, body fluids (A), blood/breast milk (C), or rash drainage (D).
The nurse is caring for a client diagnosed with meningitis. Which collaborative intervention should be included in the plan of care?
- A. Administer antibiotics.
- B. Obtain a sputum culture.
- C. Monitor the pulse oximeter.
- D. Assess intake and output.
Correct Answer: A
Rationale: Bacterial meningitis requires prompt antibiotic administration (A) as a collaborative intervention with the provider. Sputum culture (B) is not relevant, pulse oximetry (C) is supportive, and intake/output (D) is a nursing action.
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
- A. Note the first thing the client does in the seizure.
- B. Assess the size of the client’s pupils.
- C. Determine if the client is incontinent of urine or stool.
- D. Provide the client with privacy during the seizure.
Correct Answer: A
Rationale: Noting the first action (A) helps identify the seizure type and focus, aiding diagnosis and treatment. Pupil size (B), incontinence (C), and privacy (D) are secondary to ensuring safety and documenting the event.
The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?
- A. Bell's palsy.
- B. Right-sided stroke.
- C. Tetany.
- D. Mononeuropathy.
Correct Answer: A
Rationale: Bell’s palsy (A) causes unilateral facial drooping, inability to wrinkle the forehead, and eye closure issues due to facial nerve paralysis. Right-sided stroke (B) affects the opposite side, tetany (C) involves muscle spasms, and mononeuropathy (D) is less specific.