Nokea
Which client statement indicates understanding of trigeminal neuralgia management?
- A. I'll apply heat to my face for pain relief.'
- B. I'll avoid chewing on the affected side.'
- C. I'll use a hard toothbrush for oral hygiene.'
- D. I'll wash my face with cold water.'
Correct Answer: B
Rationale: Avoiding chewing on the affected side reduces pain triggers in trigeminal neuralgia.
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A 78-year-old client is admitted to the emergency department (ED) with numbness and weakness of the left arm and slurred speech. Which nursing intervention is priority?
- A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).
- B. Discuss the precipitating factors that caused the symptoms.
- C. Schedule for a STAT computed tomography (CT) scan of the head.
- D. Notify the speech pathologist for an emergency consult.
Correct Answer: C
Rationale: For a suspected stroke, the priority is to confirm the diagnosis and determine the type of stroke (ischemic or hemorrhagic) before initiating treatment. A STAT CT scan of the head is critical to rule out hemorrhagic stroke, which contraindicates thrombolytic therapy like rt-PA. Administering rt-PA without imaging could be harmful, discussing precipitating factors is not urgent, and a speech pathology consult is secondary to diagnostic imaging.
The client diagnosed with Parkinson’s disease (PD) is being admitted with a fever and patchy infiltrates in the lung fields on the chest x-ray. Which clinical manifestations of PD would explain these assessment data?
- A. Masklike facies and shuffling gait.
- B. Difficulty swallowing and immobility.
- C. Pill rolling of fingers and flat affect.
- D. Lack of arm swing and bradykinesia.
Correct Answer: B
Rationale: Difficulty swallowing and immobility (B) in PD increase aspiration risk, leading to pneumonia, which presents as fever and lung infiltrates. Other manifestations are less directly related to pulmonary complications.
The concept of intracranial regulation is identified for a client diagnosed with a brain tumor. Which intervention should the nurse include in the client’s plan of care?
- A. Tell the client to remain on bedrest.
- B. Maintain the intravenous rate at 150 mL/hour.
- C. Provide a soft, bland diet with three (3) snacks per day.
- D. Place the client on seizure precautions.
Correct Answer: D
Rationale: Brain tumors increase seizure risk, so seizure precautions (D) are essential. Bedrest (A) is unnecessary unless indicated, IV rate (B) depends on status, and diet (C) is not specific to intracranial regulation.
The home health nurse evaluates the foot care of the dark-skinned African client who has peripheral neuropathy. Which client actions in providing foot care are appropriate? Select all that apply.
- A. Uses a mirror and visually inspects the feet on a daily basis
- B. Lotions the feet and legs daily, avoiding between the toes
- C. Goes barefoot when indoors to help dry and air out the feet
- D. Wears warm socks and boots when outside in cold weather
- E. Trims toenails weekly so they have a rounded contour
- F. Inspects the feet for redness and other signs of inflammation
Correct Answer: A,B,D
Rationale: Using a mirror allows for visual inspection of the bottom of the feet and between the toes for areas of skin breakdown. Keeping the skin adequately lubricated with lotion prevents drying and cracking. Lotion should not be applied between the toes because it increases moisture and the risk for infection. Clients should avoid going barefoot because this increases the risk for foot injury. Wearing appropriate clothing protects the skin from injury because sensation is diminished with peripheral neuropathy. Toenails should be trimmed straight across to avoid damaging the tissue, which is slow to heal in the presence of peripheral neuropathy. In a dark-skinned client, areas of inflammation may appear purplish-blue or violet rather than appearing reddened (erythematous).
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.