Question 5141)
How should a nurse walk a client who is blind?
A. Stand slightly behind the client and tell her when to turn
B. Stand slightly behind and to the side of the client and guide her by holding her hand
C. Walk slightly ahead with the client’s arm inside the nurse’s arm
D. Walk beside the client and gently guide her by grasping her elbow
Answer: C
Explanation: Walking slightly ahead of the client allows the nurse to see what is in the way. The client feels more in control if her arm is through the nurse’s rather than the other way around.
Question 5142)
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
A. Encourage him to walk as far as he comfortably can
B. Suggest that he practice bending and stretching exercises
C. Walk with him, holding his arm
D. Tell him to take deep breaths while he is ambulating
Answer: C
Explanation: The client is apt to be dizzy after ear surgery. For safety, the nurse should be with him.
Question 5143)
A client complains of tinnitus and dizziness and has a diagnosis of Ménière’s disease. She asks the nurse, “What is the cause of Ménière’s disease?” What is the nurse’s best response?
A. “Ménière’s disease is caused by a virus.”
B. “The cause of Ménière’s disease is unknown.”
C. “Ménière’s disease frequently follows a streptococcal infection
D. It is hereditary - both parents are having affected genes. Answer: B Explanation: The cause of Ménière’s disease is unknown. Glomerulonephritis and rheumatic fever follow a streptococcal infection. As far as is known, Ménière’s disease is not hereditary and is not caused by a virus.
Question 5144)
An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his tem perature is slightly elevated. What does this suggest?
A. Increased cerebral blood flow
B. Respiratory depression
C. Increased intracranial pressure
D. Hyperoxygenation of the cerebrum
Answer: C
Explanation: These are classic manifestations of increased intracranial pressure.
Question 5145)
The physician has ordered mannitol IV for a client with a head injury. What should the nurse closely monitor because the client is receiving mannitol?
A. Deep tendon reflexes
B. Urine output
C. Level of orientation
D. Pulse rate
Answer: B
Explanation: Mannitol is an osmotic diuretic. Urine output should increase. He must be on intake and output.
Question 5146)
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician’s orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, “I can’t believe I really had a seizure. My mom says she was in the room when it happened, but I don’t even remember it.” What is the best interpretation of his comments?
A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
C. Inability to remember the seizure is a normal response of a person who has had a seizure.
D. They are an indication that he would rather not talk about his seizure at this time.
Answer: C
Explanation: People seldom remember a seizure; this is a normal response.
Question 5147)
What should the nurse include when teaching the client with Parkinson’s disease?
A. He should try to continue working as long as he can remain sitting most of the day.
B. Drooling may be reduced somewhat if he remembers to swallow frequently
C. He should return monthly for lab tests, which will predict the progression of the disease.
D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson’s disease.
Answer: B
Explanation: Swallowing may reduce drooling. Sitting most of the day causes stiffness. There is no lab test to determine disease progression. Emotional stress can aggravate the symptoms.
Question 5148)
A 68-year-old woman is brought to the emergency room by ambulance. She was found by her husband slumped in her chair and unresponsive. Tentative diagnosis is cerebrovascular accident (CVA). The physician orders a 15% solution of mannitol IV. The nurse knows that this drug is given for what purpose?
A. To increase urine output
B. To dissolve clots
C. To reduce blood pressure
D. To decrease muscle spasms
Answer: A
Explanation: Mannitol is an osmotic diuretic that increases urine output and will decrease intracranial pressure. Streptokinase and tPA dissolve clots and might be ordered for this client. Antihypertensive medications may also be ordered for this client.
Question 5149)
An older woman has had a CVA. The nurse notes that she seems to be unaware of objects on her right side (right homonymous hemianopia). Which nursing action is most important in planning to assist her to compensate for this loss?
A. Place frequently used items on the affected side
B. Position her so that her affected side is toward the activity in the room
C. Encourage her to turn her head from side to side to scan the environment on the affected side
D. Stand on the affected side while assisting her in ambulating
Answer: C
Explanation: Encouraging her to turn her head from side to side will do the most to help her learn a skill that will compensate for loss of the visual field. With homonymous hemianopia, the client does not see on the affected or paralyzed side. Choices 1 and 2 will make life more difficult for her. If the nurse stands on the affected side, the client will be unaware of the nurse.
Question 5150)
A client asks the nurse what causes Parkinson’s disease. The nurse’s correct reply would be that Parkinson’s disease is thought to be due to:
A. a deficiency of dopamine in the brain.
B. a demyelinating process affecting the central nervous system.
C. atrophy of the basal ganglia
D. insufficient uptake of acetylcholine in the body.
Answer: A
Explanation: A deficiency of dopamine is thought to be the cause of Parkinson’s disease. Multiple sclerosis is caused by demyelination of the central nervous system. Alzheimer’s disease involves atrophy of the basal ganglia. Myasthenia gravis is caused by insufficient uptake of acetylcholine in the body.
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