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Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.
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A client diagnosed with a subarachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?
- A. Administer a stool softener bid.
- B. Encourage the client to cough hourly.
- C. Monitor neurological status every shift.
- D. Maintain the dopamine drip to keep BP at 160/90.
Correct Answer: A
Rationale: Post-craniotomy for subarachnoid hemorrhage, preventing increased intracranial pressure is critical. A stool softener (A) prevents straining, which could raise ICP. Coughing (B) increases ICP, neurological checks (C) should be more frequent (e.g., hourly), and dopamine to maintain high BP (D) risks re-bleeding.
Which client should the nurse assess first after receiving the shift report?
- A. The client diagnosed with a stroke who has right-sided paralysis.
- B. The client diagnosed with meningitis who complains of photosensitivity.
- C. The client with a brain tumor who has projectile vomiting.
- D. The client with epilepsy who complains of tender gums.
Correct Answer: C
Rationale: Projectile vomiting (C) in a brain tumor suggests increased ICP, a life-threatening condition requiring immediate assessment. Paralysis (A), photosensitivity (B), and tender gums (D) are less urgent.
The spouse of a recently retired man tells the nurse, 'All my husband does is sit around and watch television all day long. He is so irritable and moody. I don't want to be around him.' Which action should the nurse implement?
- A. Encourage the wife to leave the client alone.
- B. Tell the wife that he is probably developing Alzheimer's disease.
- C. Recommend that the client see an HCP for an antidepressant medication.
- D. Instruct the wife to buy him some arts and crafts supplies.
Correct Answer: C
Rationale: Irritability and mood changes post-retirement may indicate depression. Recommending an HCP evaluation for antidepressants (C) is appropriate. Leaving alone (A) ignores the issue, Alzheimer’s (B) is premature, and crafts (D) may not address mood.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
The unlicensed assistive personnel (UAP) is caring for a client who is having a seizure. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The assistant attempts to insert an oral airway.
- B. The assistant turns the client on the right side.
- C. The assistant has all the side rails padded and up.
- D. The assistant does not leave the client's bedside.
Correct Answer: A
Rationale: Inserting an oral airway during a seizure (A) risks injury and is contraindicated. Turning to the side (B), padding rails (C), and staying with the client (D) are appropriate.