Question

A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?

Answer 1

Correct Answers:

Physical therapist

Rationale :

💎 A physical therapist specializes in developing and guiding exercise regimens and rehabilitation programs to help clients regain or improve strength, balance, and mobility after a stroke.

💎 They work specifically on motor skills, muscle strengthening, and functional movement training tailored to the affected side.

💎 Early referral to physical therapy promotes neuroplasticity and maximizes the client’s potential for recovery, preventing muscle atrophy and contractures.

💎 The occupational therapist focuses more on fine motor skills and activities of daily living, not primarily muscle strengthening.

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Answer 2

Correct Answers:

Relapsing-remitting multiple sclerosis

Rationale :

♦ Relapsing-remitting MS is characterized by clear relapses (periods of worsening symptoms) followed by remissions (periods with partial or total recovery and few or no symptoms).

♦ This pattern is the most common form of MS and fits the client’s description of symptom fluctuations.

♦ In contrast, primary progressive MS involves continuous progression without remissions; secondary progressive develops after relapsing-remitting but loses the remission pattern.

♦ Correct identification guides prognosis and long-term management strategies.

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Answer 3

Correct Answers

Ambulation pattern [ Parkinson's disease ; Stroke ; Multiple sclerosis ]
Muscle movements [ Parkinson's disease ; Stroke ; Multiple sclerosis ]
Speech [ Parkinson's disease ; Stroke ; Multiple sclerosis ]
Orientation status [ Parkinson's disease ; Stroke ; Multiple sclerosis ]
Facial rigidity [ Parkinson's disease ]

Rationale :

⬖ Parkinson's: Characteristic shuffling gait, slow movement, rigidity, and postural instability. ⬖ Stroke: Can cause hemiplegia or hemiparesis, resulting in altered gait or use of assistive devices. ⬖ MS: May involve spasticity, weakness, or ataxia, affecting ambulation.

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Answer 4

Correct Answers:

Notify the RN case manager of the change in status.

Rationale :

🔷 A weight gain of 1.8 kg (4 lbs) in 3 days with generalized edema indicates acute fluid retention and possible worsening heart failure, which requires prompt provider notification for timely intervention. 🔷 Documentation alone is insufficient because it does not address the acute risk. 🔷 Early notification allows for medication adjustments or urgent clinical evaluation to prevent complications like pulmonary edema. 🔷 While reinforcing daily weights and medication adherence is important, these actions do not substitute for communicating urgent changes to the case manager

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Answer 5

Correct Answers:

A client who is African American

Rationale :

♦ African American ethnicity is associated with a significantly higher risk of developing hypertension compared to other ethnicities due to genetic, social, and environmental factors.

♦ Epidemiological studies show higher prevalence and severity of hypertension and related complications in this group.

♦ Male gender and age can increase risk, but ethnicity remains the strongest factor in this scenario.

♦ Early screening and intervention are especially important in high-risk populations.

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Answer 6

Correct Answers:

Mannitol

Rationale :

💎 Mannitol is an osmotic diuretic used in cases of increased intracranial pressure (ICP) because it draws fluid out of the brain tissue into the bloodstream, effectively reducing cerebral edema.

💎 It is the standard medication to lower ICP in acute neuro cases such as subarachnoid hemorrhage.

💎 Nicardipine is a calcium channel blocker (for blood pressure), phenytoin is an anticonvulsant, and dopamine is a vasopressor.

💎 Prompt use of mannitol can help prevent brain herniation and other life-threatening complications of high ICP.

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Answer 7

Correct Answers:

Falls
Violence
Sports-related injuries

Rationale :

⬖ Falls are the leading cause of traumatic brain injuries (TBIs) in both children and older adults due to direct impact or acceleration-deceleration forces.

⬖ Violence (including assaults and gunshot wounds) is a significant cause of TBIs, especially in younger adults.

⬖ Sports-related injuries—especially contact sports—are common causes of concussions and TBIs in children and adolescents.

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Answer 8

Correct Answers:

The ST segment is above the isoelectric line.

Rationale :

🔷 ST-segment elevation is the hallmark ECG sign of an acute myocardial infarction (STEMI), reflecting acute injury to the heart muscle.

🔷 Early recognition is crucial for rapid intervention and reperfusion therapy.

🔷 Normal QRS and PR intervals do not indicate MI, and the QT interval’s relationship to the R-R interval is not relevant here.

🔷 ECG findings direct urgent management to restore blood flow and limit myocardial damage.

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Answer 9

Correct Answers:

"Incorporate walking into your daily routine."

Rationale :

♦ Walking promotes circulation, reduces risk of arterial and venous stasis, and helps prevent further progression of peripheral vascular disease.

♦ Consistent, moderate exercise is a key non-pharmacological intervention in PVD management.

♦ Elevating legs is more appropriate for venous disease, not arterial PVD; knee-length stockings can impede circulation, and shoe shopping is best done in the afternoon due to swelling, not morning.

♦ Safe activity keeps muscles and arteries healthy, reducing symptom progression.

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Answer 10

Correct Answers:

Pooling of blood and edema around the eyes
Bruising over the mastoid process

Rationale :

💎 Periorbital ecchymosis (raccoon eyes) is common with basilar skull fractures due to leakage of blood into the soft tissue around the orbits.

💎 Bruising over the mastoid process (Battle’s sign) is another classic indicator, signifying blood tracking from a basilar skull fracture.

💎 These findings support diagnosis and necessitate further neurological monitoring and imaging.

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options	Parkinson's disease	Stroke	Multiple sclerosis
Ambulation pattern
Muscle movements
Speech
Orientation status
Facial rigidity

QLexNursing

1 :
A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?

2 :
A nurse is collecting data on a client who has multiple sclerosis. The client reports there are times when the symptoms are active and times when there are no symptoms. Which of the following types of multiple sclerosis does this pattern indicate?

3 :
A nurse is caring for a client.

Correct Answers

4 :
A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

5 :
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension?

6 :
A nurse is assisting with the admission of a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse anticipate the provider prescribing to decrease ICP?

7 :
A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply)

8 :
A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea, and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?

9 :
A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

QLexNursing

1 : A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?

2 : A nurse is collecting data on a client who has multiple sclerosis. The client reports there are times when the symptoms are active and times when there are no symptoms. Which of the following types of multiple sclerosis does this pattern indicate?

3 : A nurse is caring for a client.

Correct Answers

4 : A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

5 : A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension?

6 : A nurse is assisting with the admission of a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse anticipate the provider prescribing to decrease ICP?

7 : A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply)

8 : A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea, and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?

9 : A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?

10 : A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?

1 :
A nurse is caring for a client who recently had a stroke. The client requires assistance with strengthening the affected side. Which of the following referrals should the nurse anticipate the provider to make?

2 :
A nurse is collecting data on a client who has multiple sclerosis. The client reports there are times when the symptoms are active and times when there are no symptoms. Which of the following types of multiple sclerosis does this pattern indicate?

3 :
A nurse is caring for a client.

4 :
A home health nurse is collecting data from a patient who has heart failure and notes the patient has had a weight gain of 1.8 kg (4 lb), as well as generalized edema, since the last visit 3 days ago. Which of the following actions should the nurse take next?

5 :
A nurse is reinforcing health screening education with a group of clients. The nurse should recognize that which of the following clients has the greatest risk for hypertension?

6 :
A nurse is assisting with the admission of a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse anticipate the provider prescribing to decrease ICP?

7 :
A nurse is reinforcing teaching to a group of nursing students about causes of traumatic brain injuries (TBIs). Which of the following should the nurse include in the teaching? (Select All that Apply)

8 :
A nurse is assisting with the care of a client who was admitted to the telemetry unit after he experienced chest pain, dyspnea, and diaphoresis. Which of the following ECG findings is a manifestation of acute myocardial infarction?

9 :
A nurse is reinforcing teaching with a client who has peripheral vascular disease. Which of the following instructions should the nurse include in the teaching?

10 :
A nurse has received report on a client who has a basilar skull fracture. Which of the following findings should the nurse anticipate with this client?