Nokea
Which clinical findings would the nurse find on assessment in the brain-dead client? Select all that apply.
- A. Poor skin turgor
- B. Decerebrate posturing
- C. Deep tendon reflexes
- D. Absent corneal reflex
- E. Dilated nonreactive pupils
- F. Dry mucous membranes
Correct Answer: D,E
Rationale: Absent corneal reflex and dilated nonreactive pupils are consistent with brain death, indicating loss of brainstem function.
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Which statement by a client with Alzheimer's disease indicates a need for further safety teaching?
- A. I'll use a nightlight in my bedroom.'
- B. I can cook meals on the stove alone.'
- C. I'll keep my medications in a locked box.'
- D. I'll wear a medical alert bracelet.'
Correct Answer: B
Rationale: Cooking alone on the stove poses a fire risk for clients with Alzheimer's due to memory and judgment impairments.
Based on the nurse's knowledge, which characteristic is found in Alzheimer's disease that distinguishes it from other dementias?
- A. Destruction of brain cells from hypoxia
- B. Destruction of brain cells from a stroke
- C. Neurofibrillary tangles and plaques in the brain
- D. A superficial infection in the meninges of the brain
Correct Answer: C
Rationale: Neurofibrillary tangles and amyloid plaques are hallmark pathological features of Alzheimer's disease.
The client diagnosed with a brain tumor has a diminished gag response and weakness on the left side of the body. Which intervention should the nurse implement?
- A. Make the client NPO until seen by the health-care provider.
- B. Position the client in low Fowler’s position for all meals.
- C. Place the client on a mechanically ground diet.
- D. Teach the client to direct food and fluid toward the right side.
Correct Answer: A
Rationale: A diminished gag reflex increases aspiration risk, so making the client NPO (A) is safest until swallowing is evaluated. Low Fowler’s (B) increases aspiration risk, a ground diet (C) is premature, and directing food (D) requires intact swallowing.
The nurse plans to show the spouse of the client with a suspected epidural hematoma where the epidural hematoma occurs in the brain. Which illustration should the nurse select when teaching the client’s spouse?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: B
Rationale: This illustration shows a subdural hematoma, which occurs below the dura. This illustration shows an epidural hematoma, which occurs between the skull and the dura. This illustration shows normal brain structures. An intracerebral hematoma occurs within the brain tissue and can result in brain herniation as shown in this illustration.
The client diagnosed with PD is being discharged on carbidopa/levodopa (Sinemet), an antiparkinsonian drug. Which statement is the scientific rationale for combining these medications?
- A. There will be fewer side effects with this combination than with carbidopa alone.
- B. Dopamine D requires the presence of both of these medications to work.
- C. Carbidopa makes more levodopa available to the brain.
- D. Carbidopa crosses the blood-brain barrier to treat Parkinson’s disease.
Correct Answer: C
Rationale: Carbidopa inhibits peripheral breakdown of levodopa, allowing more levodopa to cross the blood-brain barrier and convert to dopamine (C). This enhances efficacy and reduces side effects. Other options are incorrect.