Nokea
Which problem is the highest priority for the client diagnosed with West Nile virus?
- A. Alteration in body temperature.
- B. Altered tissue perfusion.
- C. Fluid volume excess.
- D. Altered skin integrity.
Correct Answer: A
Rationale: Fever (alteration in body temperature, A) is a primary symptom of West Nile virus, requiring priority management to prevent complications. Perfusion (B), fluid excess (C), and skin integrity (D) are less immediate.
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The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first?
- A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a '2' on a 1-to-10 scale.
- B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- C. The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
Correct Answer: B
Rationale: Inability to move toes in a T10 SCI (B) may indicate neurological deterioration or edema, requiring immediate assessment. Mild headache (A), emotional distress (C), and resolving hemiparesis (D) are less urgent.
Which rationale explains the transmission of the West Nile virus?
- A. Transmission occurs through exchange of body fluids when sneezing and coughing.
- B. Transmission occurs only through mosquito bites and not between humans.
- C. Transmission can occur from human to human in blood products and breast milk.
- D. Transmission occurs with direct contact from the maculopapular rash drainage.
Correct Answer: B
Rationale: West Nile virus is primarily transmitted via mosquito bites (B), not human-to-human contact, body fluids (A), blood/breast milk (C), or rash drainage (D).
The client diagnosed with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which intervention should the nurse implement prior to administering the medication?
- A. Discuss how to prevent orthostatic hypotension.
- B. Take the client's apical pulse for one (1) full minute.
- C. Inform the client that this medication is for short-term use.
- D. Tell the client to take the medication on an empty stomach.
Correct Answer: A
Rationale: Carbidopa/levodopa can cause orthostatic hypotension. Discussing prevention (A) ensures safety. Pulse (B) is not routine, the medication is long-term (C), and it can be taken with food (D) to reduce nausea.
The unlicensed assistive personnel (UAP) is caring for a client who is having a seizure. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The assistant attempts to insert an oral airway.
- B. The assistant turns the client on the right side.
- C. The assistant has all the side rails padded and up.
- D. The assistant does not leave the client's bedside.
Correct Answer: A
Rationale: Inserting an oral airway during a seizure (A) risks injury and is contraindicated. Turning to the side (B), padding rails (C), and staying with the client (D) are appropriate.
Of the following nursing observations, which is most important to discuss the client's condition?
- A. The client has a chronic cough.
- B. The client is becoming jittery.
- C. The client's skin is warm and clammy.
- D. The client develops diarrhea.
Correct Answer: A
Rationale: A chronic cough increases intrathoracic pressure, which can elevate intracranial pressure and risk aneurysm rupture.