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Which priority goal would the nurse identify for a client diagnosed with Parkinson’s Disease (PD)?
- A. The client will be able to maintain mobility and swallow without aspiration.
- B. The client will verbalize feelings about the diagnosis of Parkinson’s Disease.
- C. The client will understand the purpose of medications administered for PD.
- D. The client will have a home health agency for monitoring at home.
Correct Answer: A
Rationale: Maintaining mobility and safe swallowing (A) are priority goals in Parkinson’s to prevent falls and aspiration. Verbalizing feelings (B), understanding medications (C), and home health (D) are secondary.
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The client is undergoing post-thrombolytic therapy for a stroke. The health-care provider has ordered heparin to be infused at 1,000 units per hour. The solution comes as 25,000 units of heparin in 500 mL of D5W. At what rate will the nurse set the pump?
Correct Answer: 20 mL/hr
Rationale: Calculate: (1,000 units/hr ÷ 25,000 units) × 500 mL = 20 mL/hr. The pump should be set to 20 mL/hr.
The client is diagnosed with expressive aphasia. Which psychosocial client problem would the nurse include in the plan of care?
- A. Potential for injury.
- B. Powerlessness.
- C. Disturbed thought processes.
- D. Sexual dysfunction.
Correct Answer: B
Rationale: Expressive aphasia impairs the ability to communicate, leading to frustration and feelings of powerlessness (B). Injury (A) is physical, disturbed thought processes (C) relate to cognition, and sexual dysfunction (D) is not directly linked to aphasia.
Which intervention should the nurse implement to decrease increased intracranial pressure (ICP) for a client on a ventilator? Select all that apply.
- A. Position the client with the head of the bed up 30 degrees.
- B. Cluster activities of care.
- C. Suction the client every three (3) hours.
- D. Administer soapsuds enemas until clear.
- E. Place the client in Trendelenburg position.
Correct Answer: A
Rationale: HOB at 30 degrees (A) promotes venous drainage, reducing ICP. Clustering activities (B) increases ICP, suctioning every 3 hours (C) is excessive, enemas (D) are irrelevant, and Trendelenburg (E) worsens ICP.
The wife of the client diagnosed with chronic alcoholism tells the nurse, 'I have to call his work just about every Monday to let them know he is ill or he will lose his job.' Which would be the nurse’s best response?
- A. I am sure that this must be hard for you. Tell me about your concerns.'
- B. You are afraid he will lose his source of income.'
- C. Why would you call in for your husband? Can’t he do this?'
- D. Are you aware that when you do this you are enabling him?'
Correct Answer: A
Rationale: Reflecting and inviting discussion (A) validates the wife’s feelings and encourages therapeutic communication. Assuming fear (B) is less open-ended, questioning her actions (C) may seem judgmental, and labeling enabling (D) could alienate her.
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.