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Nstilli Nstilli
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6 years ago
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client's teaching?
 
  a. Place a warm compress on your forehead at the onset of the headache.
  b. Wear dark sunglasses when you are in brightly lit spaces.
  c. Lie down in a darkened room when you experience a headache.
  d. Set your alarm to ensure you do not sleep longer than 6 hours at one time.

Question 2

A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The client asks for options related to family planning. What is the nurse's best response?
 
  a. Most clients with the Huntington gene do not pass on Huntington disease to their children.
  b. I understand that they can diagnose this disease in embryos. Therefore, you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease.
  c. The need for family planning is limited because one of the hallmarks of Huntington disease is infertility.
  d. Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.

Question 3

A nurse prepares to discharge a client with Alzheimer's disease. Which statement should the nurse include in the discharge teaching for this client's caregiver?
 
  a. Allow the client to rest most of the day.
  b. Place a padded throw rug at the bedside.
  c. Install deadbolt locks on all outside doors.
  d. Provide a high-calorie and high-protein diet.

Question 4

A nurse cares for a client with advanced Alzheimer's disease. The client's caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
 
  a. This is a sign of fatigue. The client would benefit from a daily nap.
  b. Engage the client in scheduled activities throughout the day.
  c. It sounds like this is difficult for you. I will consult the social worker.
  d. The provider can prescribe a mild sedative for restlessness.

Question 5

A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?
 
  a. Serum electrolyte levels
  b. Kidney function tests
  c. Complete blood cell count
  d. Antinuclear antibodies

Question 6

A nurse witnesses a client with late-stage Alzheimer's disease eat breakfast. Afterward the client states, I am hungry and want breakfast. How should the nurse respond?
 
  a. I see you are still hungry. I will get you some toast.
  b. You ate your breakfast 30 minutes ago.
  c. It appears you are confused this morning.
  d. Your family will be here soon. Let's get you dressed.

Question 7

A nurse assesses a client with Alzheimer's disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
 
  a. Assess religious and spiritual needs while in the hospital.
  b. Identify the client's ability to perform self-care activities.
  c. Evaluate the client's reaction to a change of environment.
  d. Ask the client about relationships with family members.

Question 8

A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this client's plan of care?
 
  a. Ambulate the client in the hallway twice a day.
  b. Ensure a fluid intake of at least 3 liters per day.
  c. Teach the client pursed-lip breathing techniques.
  d. Keep the head of the bed at 30 degrees or greater.
Textbook 
Maternal & Child Nursing Care

Maternal & Child Nursing Care


Edition: 5th
Authors:
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6 years ago
The answer to question 1

ANS: C
At the onset of a migraine attack, the client may be able to alleviate pain by lying down and darkening the room. He or she may want both eyes covered and a cool cloth on the forehead. If the client falls asleep, he or she should remain undisturbed until awakening. The other options are not recognized therapies for migraines.

The answer to question 2

ANS: D
The presence of the Huntington gene means that the trait will be passed on to all offspring of the affected person. Understanding options for contraception and conception (e.g., surrogacy options) and implications for children may require the expertise of a genetic counselor or a reproductive specialist. The other statements are not accurate.

The answer to question 3

ANS: C
Clients with Alzheimer's disease have a tendency to wander, especially at night. If possible, alarms should be installed on all outside doors to alert family members if the client leaves. At a minimum, all outside doors should have deadbolt locks installed to prevent the client from going outdoors unsupervised. The client should be allowed to exercise within his or her limits. Throw rugs are a slip and fall hazard and should be removed. The client should eat a well-balanced diet. There is no need for a high-calorie or high-protein diet.

The answer to question 4

ANS: B
Several strategies may be used to cope with restlessness and wandering. One strategy is to engage the client in structured activities. Another is to take the client for frequent walks. Daily naps and a mild sedative will not be as effective in the management of restless behavior. Consulting the social worker does not address the caregiver's concern.

The answer to question 5

ANS: B
Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.

The answer to question 6

ANS: A
Use of validation therapy with clients who have Alzheimer's disease involves acknowledgment of the client's feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client's concerns.

The answer to question 7

ANS: C
As Alzheimer's disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client's reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client's reaction to environmental change.

The answer to question 8

ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the client's blood. Pursed-lip breathing increases exhalation of carbon dioxide.
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