Nokea
Which sign or symptom in the client's medical history would most likely indicate a manifestation of the client's disease?
- A. Sudden hearing loss
- B. Sensitivity to light
- C. Drooping eyelids
- D. Protruding tongue
Correct Answer: C
Rationale: Drooping eyelids (ptosis) is a common symptom of myasthenia gravis due to muscle weakness affecting the ocular muscles.
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The charge nurse is making client assignments for a neuro-medical floor. Which client should be assigned to the most experienced nurse?
- A. The elderly client who is experiencing a stroke in evolution.
- B. The client diagnosed with a transient ischemic attack 48 hours ago.
- C. The client diagnosed with Guillain-Barré syndrome who complains of leg pain.
- D. The client with Alzheimer's disease who is wandering in the halls.
Correct Answer: A
Rationale: A stroke in evolution (A) is an acute, progressing condition requiring experienced monitoring. TIA (B) is stable, Guillain-Barré pain (C) is manageable, and wandering (D) needs supervision but is less acute.
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
- A. Perform passive ROM every two (2) hours.
- B. Maintain a negative nitrogen balance.
- C. Encourage a low-protein, soft-mechanical diet.
- D. Turn the client and have him cough and deep breathe every shift.
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (A) prevents contractures and maintains comfort. Negative nitrogen balance (B) is undesirable, low-protein diets (C) are not indicated, and coughing/deep breathing (D) may be infeasible.
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.
Which should be the nurse's first intervention with the client diagnosed with Bell's palsy?
- A. Explain that this disorder will resolve within a month.
- B. Tell the client to apply heat to the involved side of the face.
- C. Encourage the client to eat a soft diet.
- D. Teach the client to protect the affected eye from injury.
Correct Answer: D
Rationale: Bell’s palsy impairs eye closure, risking corneal damage. Teaching eye protection (D) is the priority. Resolution timeline (A), heat (B), and diet (C) are secondary.