Nokea
Which intervention is priority for a client with AIDS dementia complex experiencing agitation?
- A. Administer a sedative as prescribed.
- B. Provide a quiet, low-stimulus environment.
- C. Restrain the client to prevent injury.
- D. Encourage group activities to distract the client.
Correct Answer: B
Rationale: A quiet, low-stimulus environment reduces agitation in clients with AIDS dementia complex by minimizing sensory overload.
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Which nursing action is priority when caring for a client with suspected brain death?
- A. Administer pain medication.
- B. Perform a neurologic assessment.
- C. Increase fluid intake.
- D. Encourage family visitation.
Correct Answer: B
Rationale: A thorough neurologic assessment is critical to confirm brain death criteria, guiding further care decisions.
The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
- A. The assistant places a gait belt around the client's waist prior to ambulating.
- B. The assistant places the client on the back with the client's head to the side.
- C. The assistant places a hand under the client's right axilla to move up in bed.
- D. The assistant praises the client for attempting to perform ADLs independently.
Correct Answer: C
Rationale: Placing a hand under the axilla (C) to move a client with right-sided paralysis risks shoulder subluxation or injury to the weak side. A gait belt (A) is appropriate for safe ambulation, positioning with head to the side (B) prevents aspiration, and praising independence (D) is therapeutic.
The client is diagnosed with Wernicke-Korsakoff syndrome as a result of chronic alcoholism. For which symptoms would the nurse assess?
- A. Insomnia and anxiety.
- B. Visual or auditory hallucinations.
- C. Extreme tremors and agitation.
- D. Ataxia and confabulation.
Correct Answer: D
Rationale: Wernicke-Korsakoff syndrome, due to thiamine deficiency in alcoholism, causes ataxia (unsteady gait) and confabulation (fabricated memories, D). Insomnia/anxiety (A), hallucinations (B), and tremors/agitation (C) are less specific.
The client has glossopharyngeal nerve (cranial nerve IX) paralysis secondary to a stroke. Which referral would be most appropriate for this client?
- A. Hospice nurse.
- B. Speech therapist.
- C. Physical therapist.
- D. Occupational therapist.
Correct Answer: B
Rationale: Glossopharyngeal nerve paralysis affects swallowing and speech. A speech therapist (B) is most appropriate to address these deficits. Hospice (A) is for end-of-life care, physical therapy (C) focuses on mobility, and occupational therapy (D) addresses daily activities.
Which is a common cognitive problem associated with Parkinson’s disease?
- A. Emotional lability.
- B. Depression.
- C. Memory deficits.
- D. Paranoia.
Correct Answer: B
Rationale: Depression (B) is a common cognitive/emotional problem in Parkinson’s due to dopamine dysregulation and chronic illness impact. Emotional lability (A) is less common, memory deficits (C) occur later, and paranoia (D) is not typical.