Nokea
Which intervention should be added to the client's care plan in relation to this latest finding?
- A. Have the client wear dark glasses when in bright light.
- B. Cover the client's affected eye with an eye patch.
- C. Approach the client from the unaffected side.
- D. Position food on the tray resembling the face of a clock.
Correct Answer: C
Rationale: Approaching from the unaffected side ensures the client with hemianopia can see the nurse, compensating for visual field loss.
You may also like to solve these questions
The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?
- A. Assess the client's sense of smell and taste.
- B. Teach the client how to care for the eyes.
- C. Instruct the client to have carbamazepine (Tegretol) levels monitored Multiple Choicely.
- D. Assist the client to identify factors that trigger an attack.
Correct Answer: C
Rationale: Carbamazepine is a primary treatment for trigeminal neuralgia, and Multiple Choice monitoring of levels (C) prevents toxicity and ensures efficacy. Smell/taste (A) are unaffected, eye care (B) is relevant for Bell’s palsy, and triggers (D) are secondary to medication management.
When assisting the client with activities of daily living (ADLs), which approach is best?
- A. Limit the time for performing ADLs to 30 minutes.
- B. Eliminate whatever tasks the client cannot perform.
- C. Let the client rest between activities.
- D. Perform all of the client's ADLs at this time.
Correct Answer: C
Rationale: Allowing rest between activities conserves energy and supports the client's independence during an MS exacerbation.
The nurse asks the male client with epilepsy if he has auras with his seizures. The client says, 'I don’t know what you mean. What are auras?' Which statement by the nurse would be the best response?
- A. Some people have a warning that the seizure is about to start.'
- B. Auras occur when you are physically and psychologically exhausted.'
- C. You’re concerned that you do not have auras before your seizures?'
- D. Auras usually cause you to be sleepy after you have a seizure.'
Correct Answer: A
Rationale: Auras are sensory warnings preceding a seizure (A), and this response accurately educates the client. Other options misdefine auras (B, D) or fail to address the question (C).
When the client asks why fluids are being restricted, which explanation by the nurse is best?
- A. Large amounts of fluid may contribute to vomiting.'
- B. The kidneys need to conserve fluid output.'
- C. Fluid restriction reduces the volume in the cranium.'
- D. The prescribed volume is sufficient for relieving thirst.'
Correct Answer: C
Rationale: Fluid restriction reduces intracranial volume, minimizing the risk of increased intracranial pressure post-craniotomy.
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.