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Which signs and symptoms will the nurse detect with this disorder? Select all that apply.
- A. Speech by the client to consume a high-fiber diet
- B. Rapid heart rate
- C. Pounding headache
- D. Pale skin
- E. Blurred vision
- F. Nasal stuffiness
Correct Answer: C,E,F
Rationale: Autonomic dysreflexia presents with a pounding headache, blurred vision, and nasal stuffiness due to unopposed sympathetic activity.
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The charge nurse is making assignments. Which client should be assigned to the new graduate nurse?
- A. The client diagnosed with aseptic meningitis who is complaining of a headache and the light bothering his eyes.
- B. The client diagnosed with Parkinson’s disease who fell during the night and is complaining of difficulty walking.
- C. The client diagnosed with a cerebrovascular accident whose vital signs are P 60, R 14, and BP 198/68.
- D. The client diagnosed with a brain tumor who has a new complaint of seeing spots before the eyes.
Correct Answer: A
Rationale: Aseptic meningitis with headache and photophobia (A) is a stable condition suitable for a new graduate, requiring basic symptom management. Parkinson’s with a fall (B) needs fall risk assessment, CVA with high BP (C) requires experienced intervention, and brain tumor with visual changes (D) suggests progression needing expertise.
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?
- A. Assess neurological status.
- B. Monitor pulse, respiration, and blood pressure.
- C. Initiate an intravenous access.
- D. Maintain an adequate airway.
Correct Answer: D
Rationale: Airway maintenance (D) is the highest priority in any critically ill patient, including those with head injuries, to ensure oxygenation. Neurological assessment (A), vital signs (B), and IV access (C) follow after securing the airway.
The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
- A. Crackles in the upper lung fields and jugular vein distention.
- B. Muscle weakness in the upper extremities and ptosis.
- C. Exaggerated arm swinging and scanning speech.
- D. Masklike facies and a shuffling gait.
Correct Answer: D
Rationale: Masklike facies and shuffling gait (D) are hallmark signs of Parkinson’s due to bradykinesia and rigidity. Crackles and JVD (A) suggest heart failure, weakness and ptosis (B) indicate myasthenia gravis, and exaggerated arm swinging (C) is opposite to Parkinson’s.
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.
Which activity should the nurse encourage for a client with early Parkinson's disease to improve mobility?
- A. High-intensity aerobic exercise
- B. Daily stretching and balance exercises
- C. Weightlifting three times weekly
- D. Complete bed rest during tremors
Correct Answer: B
Rationale: Stretching and balance exercises improve mobility and reduce fall risk in early Parkinson's disease.