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Which client would the nurse identify as being most at risk for experiencing a cerebrovascular accident (CVA)?
- A. A 55-year-old African American male.
- B. An 84-year-old Japanese female.
- C. A 67-year-old Caucasian male.
- D. A 39-year-old pregnant female.
Correct Answer: B
Rationale: Risk factors for CVA include advanced age, hypertension, diabetes, and ethnicity, with African Americans and Asians at higher risk. An 84-year-old Japanese female is at the highest risk due to her age and potential for comorbidities like hypertension, which is prevalent in older populations. A 55-year-old African American male is also at risk, but age is a stronger factor. Pregnancy increases risk but is less significant compared to advanced age.
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The student nurse asks the nurse, 'Why do you ask the client to identify how many fingers you have up when the client hit the front of the head, not the back?' The nurse would base the response on which scientific rationale?
- A. This is part of the routine neurological examination.
- B. This is done to determine if the client has diplopia.
- C. This assesses the amount of brain damage.
- D. This is done to indicate if there is a rebound effect on the brain.
Correct Answer: B
Rationale: Frontal head injuries may affect the occipital lobe or optic pathways, causing diplopia (double vision, B). Routine exams (A) are broader, brain damage (C) is not specific, and rebound effect (D) is not a term used here.
The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis?
- A. Positive Babinski’s sign and peripheral paresthesia.
- B. Negative Chvostek’s sign and facial tingling.
- C. Positive Kernig’s sign and nuchal rigidity.
- D. Negative Trousseau’s sign and nystagmus.
Correct Answer: C
Rationale: Kernig’s sign (pain with leg extension) and nuchal rigidity (C) are hallmark signs of bacterial meningitis due to meningeal irritation. Other options include unrelated or less specific findings.
Which nursing action would be most appropriate if the client develops anorexia and nausea while taking interferon beta-1a (Avonex)?
- A. Withhold the medication.
- B. Offer frequent mouth care.
- C. Administer the drug after meals.
- D. Provide small, easy to digest meals.
Correct Answer: D
Rationale: Providing small, easy-to-digest meals helps manage nausea and encourages nutritional intake without altering the medication schedule.
The male client diagnosed with a brain tumor is scheduled for a magnetic resonance imaging (MRI) scan in the morning. The client tells the nurse that he is scared. Which response by the nurse indicates an appropriate therapeutic response?
- A. MRIs are loud but there will not be any invasive procedure done.'
- B. You’re scared. Tell me about what is scaring you.'
- C. This is the least thing to be scared about—there will be worse.'
- D. I can call the MRI tech to come and talk to you about the scan.'
Correct Answer: B
Rationale: Reflecting the client’s fear (B) encourages expression of concerns, fostering therapeutic communication. Other options provide information (A, D) or minimize feelings (C).
The nurse researcher is working with clients diagnosed with Parkinson’s disease. Which is an example of an experimental therapy?
- A. Stereotactic pallidotomy/thalamotomy.
- B. Dopamine receptor agonist medication.
- C. Physical therapy for muscle strengthening.
- D. Fetal tissue transplantation.
Correct Answer: D
Rationale: Fetal tissue transplantation (D) is an experimental therapy for Parkinson’s, investigated for dopamine-producing cell replacement. Pallidotomy/thalamotomy (A) and dopamine agonists (B) are established, and physical therapy (C) is standard care.