Nokea
Which intervention is most appropriate for a client with multiple sclerosis experiencing fatigue?
- A. Schedule activities in the late afternoon.
- B. Encourage short, frequent rest periods.
- C. Administer caffeine supplements.
- D. Increase physical therapy sessions.
Correct Answer: B
Rationale: Short, frequent rest periods help manage fatigue in multiple sclerosis by conserving energy.
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The client is being evaluated to rule out ALS. Which signs/symptoms would the nurse note to confirm the diagnosis?
- A. Muscle atrophy and flaccidity.
- B. Fatigue and malnutrition.
- C. Slurred speech and dysphagia.
- D. Weakness and paralysis.
Correct Answer: C
Rationale: Slurred speech and dysphagia (C) are early ALS signs due to bulbar muscle involvement. Atrophy/flaccidity (A) and weakness/paralysis (D) occur later, and fatigue/malnutrition (B) are nonspecific.
Which intervention is most appropriate for a client with a cerebral aneurysm at risk for rupture?
- A. Encourage deep coughing exercises.
- B. Maintain a quiet, dimly lit environment.
- C. Administer high-dose corticosteroids.
- D. Promote early ambulation.
Correct Answer: B
Rationale: A quiet, dimly lit environment reduces stimuli that could increase intracranial pressure and risk aneurysm rupture.
Which nursing intervention is most appropriate after the lumbar puncture has been performed?
- A. Keep the client in a side-lying position.
- B. Assist the client into a sitting position.
- C. Withhold food and fluids for 1 hour.
- D. Keep the client flat for several hours.
Correct Answer: D
Rationale: Keeping the client flat for several hours post-lumbar puncture reduces the risk of cerebrospinal fluid leakage and subsequent headache.
The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statements by the nurse will be helpful to the client? Select all that apply.
- A. “You need to continue to use contraceptives if you do not wish to have children.”
- B. “Unfortunately, your injury prevents you from being able to conceive children.”
- C. “Because feeling is affected, it is not likely that you will be able to deliver a baby.”
- D. “Sexual intercourse is generally prohibited because it can worsen your condition.”
- E. “You can engage in sexual intimacy, but you may not be able to feel an orgasm.”
Correct Answer: A,E
Rationale: Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. The client with an incomplete T6 SCI is able to get pregnant. Although the client may not feel the onset of labor, she may still be able to deliver the baby vaginally or via cesarean section. Sexual intercourse is allowable and would not worsen the client’s condition. The female may not be able to feel an orgasm. The client may not be able to feel an orgasm after an incomplete T6 SCI.
The nurse is caring for several clients. Which client would the nurse assess first after receiving the shift report?
- A. The 22-year-old male client diagnosed with a concussion who is complaining someone is waking him up every two (2) hours.
- B. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a magnetic resonance imaging (MRI) scan.
- C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale (GCS) score of 6.
- D. The 62-year-old client diagnosed with a cerebrovascular accident (CVA) who has expressive aphasia.
Correct Answer: C
Rationale: A GCS score of 6 (C) indicates severe neurological impairment, requiring immediate assessment for potential life-threatening conditions. Waking every 2 hours (A) is standard for concussion, left-sided weakness (B) is concerning but less acute, and expressive aphasia (D) is stable.