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Which intervention is most appropriate for a client diagnosed with Bell's palsy?
- A. Reduce the amount of light in the room.
- B. Advise the client to drink liquids from a straw.
- C. Inspect the buccal pouch for food after eating.
- D. Instruct the client on how to walk with a cane.
Correct Answer: B
Rationale: Drinking from a straw helps clients with Bell's palsy manage liquids, compensating for facial muscle weakness.
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The nurse is caring for the client who, 6 weeks after an MVA, was diagnosed with a mild TBI. Which information in the client’s history of the injury should the nurse associate with the TBI? Select all that apply.
- A. The client has had no episodes of vomiting after the accident.
- B. The client remembers events before and right after the accident.
- C. The client has had headache and dizziness daily since the accident.
- D. The client has difficulty concentrating and focusing while at work.
- E. The client lost consciousness momentarily at the time of the injury.
Correct Answer: C,D,E
Rationale: The client with mild TBI usually experiences symptoms commonly associated with mild concussion, such as vomiting. The client with mild TBI usually experiences amnesia and is unable to recall events regarding the accident. Recurrent problems with headache and dizziness are the most prominent symptoms of mild TBI. Cognitive difficulties, including inability to concentrate and forgetfulness, occur with mild TBI. At the time of the accident, the person with mild TBI may experience a loss of consciousness for a few seconds or minutes.
The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?
- A. The client has cogwheel rigidity when moving the upper extremities.
- B. The client has a decrease in the frequency and severity of tremors.
- C. The client has less facial pain and converses with more facial expression.
- D. The client no longer experiences auras or a severe frontal headache.
Correct Answer: B
Rationale: Cogwheel rigidity, a symptom of PD, is interrupted muscular movement and is not treated with the DBS. DBS is a treatment used for intractable tremors associated with PD. The electrical current interferes with the brain cells initiating the tremors. Severe facial pain is associated with trigeminal neuralgia, not PD rau. The DBS will not affect facial expression. Auras are unusual sensations experienced before a seizure occurs and are not associated with PD.
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
- A. Perform passive ROM every two (2) hours.
- B. Maintain a negative nitrogen balance.
- C. Encourage a low-protein, soft-mechanical diet.
- D. Turn the client and have him cough and deep breathe every shift.
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (A) prevents contractures and maintains comfort. Negative nitrogen balance (B) is undesirable, low-protein diets (C) are not indicated, and coughing/deep breathing (D) may be infeasible.
When planning care for a client with a stroke, which goal is most appropriate for addressing dysphagia?
- A. The client will swallow soft foods without choking.
- B. The client will eat three full meals daily.
- C. The client will gain 2 pounds in one week.
- D. The client will verbalize hunger before meals.
Correct Answer: A
Rationale: Swallowing soft foods without choking is a realistic and safe goal for managing dysphagia in stroke clients.
The client is reporting neck pain, fever, and a headache. The nurse elicits a positive Kernig's sign. Which diagnostic test procedure should the nurse anticipate the HCP ordering to confirm a diagnosis?
- A. A computed tomography (CT).
- B. Blood cultures times two (2).
- C. Electromyogram (EMG).
- D. Lumbar puncture (LP).
Correct Answer: D
Rationale: Neck pain, fever, headache, and positive Kernig’s sign suggest meningitis. A lumbar puncture (D) confirms the diagnosis via CSF analysis. CT (A) may precede LP, blood cultures (B) are supportive, and EMG (C) is unrelated.