-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
... [Show More] 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. [Show Less]