Nokea
Which intervention should the nurse take with the client recently diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease)?
- A. Discuss a percutaneous gastrostomy tube.
- B. Explain how a fistula is accessed.
- C. Provide an advance directive.
- D. Refer to a physical therapist for leg braces.
Correct Answer: C
Rationale: ALS is progressive and terminal. Providing an advance directive (C) ensures the client’s wishes are respected early. Gastrostomy (A) is later, fistulas (B) are unrelated, and leg braces (D) are less urgent.
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Which nursing approach for communication would be best if the client becomes confused?
- A. Turn the television on so the client can hear human voices.
- B. Play some music when the client is aggressive.
- C. Orient the client to the surroundings and current situations.
- D. Look at and talk about pictures in a photo album of the client's life.
Correct Answer: C
Rationale: Orienting the client to their surroundings and current situations helps reduce confusion and anxiety in clients with AIDS dementia complex.
Which teaching topics should the nurse cover before discharge? Select all that apply.
- A. Dietary restrictions
- B. Avoiding heavy lifting
- C. Staying out of bright sunlight
- D. Missed doses
- E. Bruising or blood in urine
- F. Need for frequent laboratory work
Correct Answer: A,D,E,F
Rationale: Warfarin requires dietary consistency, instructions on missed doses, monitoring for bleeding (bruising/blood in urine), and frequent INR checks.
The nurse is planning the care for a client diagnosed with Parkinson’s disease. Which would be a therapeutic goal of treatment for the disease process?
- A. The client will experience periods of akinesia throughout the day.
- B. The client will take the prescribed medications correctly.
- C. The client will be able to enjoy a family outing with the spouse.
- D. The client will be able to carry out activities of daily living.
Correct Answer: D
Rationale: A therapeutic goal for Parkinson’s disease is to maximize functional ability, such as carrying out ADLs (D). Akinesia (A) is a symptom to minimize, medication adherence (B) is a means to the goal, and family outings (C) are less specific.
If the client had been unresponsive except to painful stimuli, which new assessment finding indicates that the client is improving?
- A. Pupils are fixed when stimulated with light.
- B. Pupils are unequal when stimulated with light.
- C. Client's Glasgow Coma Scale score is 12.
- D. Stroking the cheek with a swab causes swallowing.
Correct Answer: C
Rationale: A Glasgow Coma Scale score of 12 indicates improved responsiveness compared to being unresponsive except to painful stimuli, suggesting neurological improvement.
The nurse is caring for a client with increased intracranial pressure (ICP) who has secretions pooled in the throat. Which intervention should the nurse implement first?
- A. Set the ventilator to hyperventilate the client in preparation for suctioning.
- B. Assess the client’s lung sounds and check for peripheral cyanosis.
- C. Turn the client to the side to allow the secretions to drain from the mouth.
- D. Suction the client using the in-line suction, wait 30 seconds, and repeat.
Correct Answer: C
Rationale: Pooled secretions risk airway obstruction. Turning to the side (C) clears the airway safely without increasing ICP. Hyperventilation (A) and suctioning (D) may raise ICP, and assessment (B) delays intervention.