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Which nursing action is priority for a client with a stroke experiencing unilateral neglect?
- A. Place objects on the unaffected side.
- B. Encourage bilateral arm exercises.
- C. Provide a mirror for self-awareness.
- D. Teach the client to scan the environment.
Correct Answer: D
Rationale: Teaching the client to scan the environment compensates for unilateral neglect, promoting safety and awareness.
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Which clinical manifestation is the educator most likely to include as the initial sign of Parkinson's disease?
- A. Muscle rigidity
- B. Muscle tremors
- C. Muscle weakness
- D. Muscle deterioration
Correct Answer: B
Rationale: Muscle tremors, particularly resting tremors, are often the initial sign of Parkinson's disease.
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 male client is sitting in the chair and his entire body is rigid with his arms and legs contracting and relaxing. The client is not aware of what is going on and is making guttural sounds. Which action should the nurse implement first?
- A. Push aside any furniture.
- B. Place the client on his side.
- C. Assess the client’s vital signs.
- D. Ease the client to the floor.
Correct Answer: D
Rationale: During a tonic-clonic seizure, the priority is safety. Easing the client to the floor (D) prevents injury from falling. Clearing furniture (A) follows, placing on the side (B) is done after the client is safe, and vital signs (C) are assessed post-seizure.
Because the client with Parkinson's disease is prone to constipation, the nurse should encourage increased consumption of which food?
- A. Fresh fruits
- B. Wheat pasta
- C. Low-fat cheese
- D. Canned vegetables
Correct Answer: A
Rationale: Fresh fruits are high in fiber, which helps alleviate constipation in clients with Parkinson's disease.
The client with MS tells the nurse about extreme fatigue. Which assessment findings should the nurse identify as contributing to the client's fatigue? Select all that apply.
- A. Hemoglobin 9.5 g/dL and hematocrit is 31.8%
- B. Taking baclofen 15 mg 3 times per day
- C. Working 4 to 8 hours per week in the family business
- D. Stopped taking amitriptyline 8 weeks earlier
- E. Presence of a cardiac murmur at the tricuspid valve.
- F. Bilateral leg weakness noted when walking in room
Correct Answer: A,B,D,E,F
Rationale: The lower-than-normal Hgb and Hct indicate anemia. Inadequate cell oxygenation contributes to fatigue. Baclofen (Lioresal), a skeletal muscle relaxant used to relieve spasms, has the adverse effects of drowsiness and fatigue. Working 4 to 8 hours per week is a limited number of hours and should not contribute to the client’s fatigue. The client has stopped amitriptyline (Elavil), an antidepressant, and may be clinically depressed. Fatigue is a major symptom of depression. A tricuspid murmur indicates an incompetent cardiac valve, which will decrease the amount of oxygenated blood reaching the tissues. The increased energy expenditure with ambulation can increase fatigue.