-A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
CORRECT ANSWER = Speak to the client about one idea at a time
RATIONALE = The nurse should speak using sentences that contain one clear thought or idea for better communication and unde...
-A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?
CORRECT ANSWER = Speak to the client about one idea at a time
RATIONALE = The nurse should speak using sentences that contain one clear thought or idea for better communication and
understanding.
Incorrect: Ask the client to multi-task.
The nurse use simple one-step directions, rather than ask the client to multi-task.
Incorrect: Limit questions to yes and no answers.
The nurse should avoid asking questions that stimulate "yes" and "no" responses because the client might give automatic responses that
are not correct.
Incorrect: Focus on a single form of communication.
The nurse should include a variety of aids to assist with communication.
-A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations
should the nurse expect?
Incorrect: Gradual onset of several hours
A client who has a thrombotic (ischemic) stroke will have a gradual onset of manifestations occurring over several minutes to hours. A
client who has had a hemorrhagic stroke tends to have an acute onset.
CORRECT ANSWER = Manifestations preceded by a severe headache
RATIONALE = A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by
hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a
hemorrhagic stroke.
Incorrect: Maintains consciousness
A client who has an ischemic stroke maintains a level of consciousness. A client who has a hemorrhagic stroke has a decreased level of
consciousness, extending from stupor to coma.
Incorrect: History of neurologic deficits lasting less than 1 hr
A client who has an ischemic stroke might have experienced transient ischemic attacks that caused neurologic deficits lasting for short
periods of time before. These transient attacks are not present in a client who has had a hemorrhagic stroke.
-A nurse is caring for a client who has Parkinson’s disease and is taking diphenhydramine 25 mg PO TID. Which of the following therapeutic
outcomes should the nurse expect to see?
Incorrect: Delay in disease progression
Diphenhydramine may be helpful in controlling symptoms in the early stage of the disease; however, it will not delay disease progression.
Incorrect: Improved bladder function
Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may cause urinary retention.
Incorrect: Relief of depression
Relief of depression is not associated with the use of antihistamines or anticholinergics.
CORRECT ANSWER = Decreased tremors
RATIONALE = Clients who have Parkinson's disease often experience trembling, muscle rigidity, difficulty walking, and problems with
balance and coordination. Antihistamines, like diphenhydramine, have a mild anticholinergic effect and may be helpful in controlling
tremors in the early stage of the disease.
-A nurse is teaching a client who is taking benztropine to treat Parkinson’s disease. The nurse should instruct the client to report which of the
following adverse effects?
Incorrect: Excess salivation
Dry mouth is an adverse effect of benztropine, due to the anticholinergic response of the medication.
CORRECT ANSWER = Difficulty voiding
RATIONALE = The nurse should instruct the client to report difficulty voiding, which may indicate urinary retention, as an adverse effect of
benztropine. Benztropine is an anticholinergic medication that helps decrease the rigidity and tremors of Parkinson’s disease.
Incorrect: Diarrhea
Constipation is an adverse effect of benztropine, which is due to the anticholinergic response of the medication that slows peristalsis.
Incorrect: Slow pulse
Tachycardia is an adverse effect of benztropine, which is due to the anticholinergic response of the medication.
-A nurse who is off duty finds a woman who has collapsed and has right-sided weakness and slurred speech. Which of the following actions should
the nurse take?
Incorrect: Obtain the telephone number of the client's provider.
This action could delay treatment and result in further injury and disability.
Incorrect: Find a location for the client to sit.
The nurse should support the client where she is and try to make her comfortable while ensuring airway patency. But she should not
attempt to move her.
CORRECT ANSWER = Call emergency services.
RATIONALE = The client might have had a stroke, and if she has, she needs emergency medical intervention and transport to a stroke
center.
Incorrect: Drive the client to the nearest emergency department.
The nurse should support the client where she is and try to make her comfortable while ensuring airway patency. But she should not
attempt to move her, as doing so could cause additional injury and disability.
,-A nurse is planning care for a client who has a cerebral aneurysm. Which of the following actions should the nurse plan to take?
Incorrect: Elevate the head of bed to 45°.
The nurse should elevate the head of the client's bed no higher than 30° to support venous return and lower intracranial pressure. In
some cases, the bed should remain flat to increase cerebral perfusion.
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CORRECT ANSWER = Maintain the client on absolute bed rest.
, The nurse should place the client on absolute bed rest in a quiet environment. Activity can elevate blood pressure and increase the risk for
bleeding.
Incorrect: Administer a cleansing enema.
The nurse should not administer an enema because straining or discomfort can elevate the client's blood pressure and increase
intracranial pressure.
Incorrect: Place the client in a room near the nurses' station.
The nurse should maintain the client on bed rest in a quiet, non-stressful environment.
-A nurse caring for a client who had a right-sided stroke and is exhibiting homonymous hemianopsia when eating. Which of the following actions
should the nurse take?
Incorrect: Provide a nonskid mat to alleviate plate movement.
The nurse should provide a nonskid mat to alleviate plate movement, but this action does not resolve the problem of homonymous
hemianopsia.
Incorrect: Encourage the client to use his right hand when feeding himself.
The nurse should encourage the client to use his right hand when feeding himself, but this action does not resolve the problem of
homonymous hemianopsia.
CORRECT ANSWER = Remind the client to look for food on the left side of the tray.
RATIONALE =The nurse's action to remind the client to look for food on the left side of the tray will train the client to scan the tray by
moving his head and eyes, which will help to resolve the problem of homonymous hemianopsia.
Incorrect: Encourage the use of the wide grip utensils.
The nurse should encourage the client to use wide grip utensils, but this action does not resolve the problem of homonymous
hemianopsia.
-A nurse is caring for a client who is scheduled to have a MRI scan. The client askes the nurse what to expect during the procedure. Which of the
following statements should the nurse make?
Incorrect: "An MRI scan is not distorted by movement, so you do not have to lie still."
An MRI scan is distorted by movement. It is important that the client is informed of the need to lie still during the procedure.
Incorrect:"An MRI scan is a short procedure and should take no longer than 30
minutes." An MRI scan is a lengthy procedure that lasts between 60 and 90
min.
Incorrect: "The MRI contrast dye contains iodine and can cause your skin to itch."
MRI contrast dye does not contain iodine and therefore is not subject to hypersensitivity reactions like contrast dye used in a traditional
CT scan.
CORRECT ANSWER = "An MRI scan is very noisy, and you will be allowed to wear earplugs while in the scanner."
RATIONALE = The nurse should instruct the client that many clients report being disconcerted by the loud thumping and humming noises
produced by the scanner, and for that reason, earplugs are offered to reduce the discomfort.
-A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow coma scale score of 3 for eye opening, 5 for
verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?
Incorrect: The client can follow simple motor commands.
The client's ability to follow commands would require a score of 6 for best motor response.
Incorrect: The client is unable to make vocal sound.
The inability of the client to make vocal sounds would result in a score of 1 for best verbal response.
Incorrect: The client is unconscious.
The unconscious client would have a score of 1 for eye opening and a 1 for best verbal response.
CORRECT ANSWER = The client opens his eyes when spoken to.
A GCS of 3-5-5 indicates that the client opens his eyes in response to speech, is oriented, and is able to localize pain.
-A nurse is shopping and finds a woman who has collapsed with right sided weakness and slurred speech. Which of the following actions should the
nurse take?
Incorrect: Provide the client with water to test the gag reflex.
The nurse should not give the client anything to eat or drink in case the client's gag reflex is impaired, as this could cause aspiration.
Assessment of swallowing ability can be performed when the client is stable and equipment to suction the client's airway is available.
Incorrect: Perform carotid massage.
The nurse should understand carotid massage is used to correct atrioventricular tachycardia. The technique will not improve the client's
condition and could cause harm if the client has carotid stenosis.
CORRECT ANSWER = Notify emergency management services.
The client is exhibiting manifestations of a stroke and a rapid diagnosis is vital to administering appropriate treatment; therefore, the
nurse should call the emergency management services.
Incorrect: Drive the client to the nearest medical facility.
The nurse should not attempt to drive the client away from the scene. The nurse should position the client to maintain an open airway.
-A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? Select all that apply.
CORRECT ANSWER = Loosen restrictive clothing.
RATIONALE: Loosening clothing, such as a belt or collar, aids in respiratory and abdominal expansion. The client should not be restrained.
Incorrect: Insert a bite stick into the client's mouth.
A bite stick or padded tongue blade can cause an obstruction in the client's airway or further injury if teeth are broken as a result of
the jaw clamping down on the bite stick.
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