Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

Provide step by step verbal directions.

Orient the client to the color coding system used for locating hospital services.

Use the hospital map to show the client where the cafeteria is located.

Escort the client to the cafeteria.

Answer and Explanation

The Correct Answer is D

D. For individuals with Huntington's disease, who may experience motor impairments and difficulties with coordination and balance, having someone escort them to the cafeteria could be the most practical and supportive approach.

A. Verbal directions may be a component of assistance but they may not be the most effective approach on their own.

B. Individuals with Huntington's disease may still have difficulties with executive function and orientation, which could limit their ability to effectively use a color coding system independently.

C. Providing a visual representation of the hospital layout using a map could be a helpful approach for a client with Huntington's disease. However, the cognitive and motor impairment present may hinder access even in the presence of a map.

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Correct Answer is ["C","E","H"]

Explanation

A. Send blood for a complete blood count, electrolytes: This is appropriate for assessing the client's overall health status and electrolyte balance, which may be affected by pneumonia and enalapril therapy.

B.Enalapril 10 mg every morning: This is the client's maintenance dose of enalapril for managing hypertension, and it should be continued unless there are specific contraindications or concerns about renal function.

C.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase blood pressure and interfere with the antihypertensive effects of enalapril. Additionally, NSAIDs can potentially worsen renal function, which may already be compromised in a client with pneumonia.
D.Admit to the medical floor: This is appropriate for a client with pneumonia who may require close monitoring and management of respiratory status and other complications.
E.Supplemental oxygen 10 L/min via nasal cannula: High-flow oxygen can decrease respiratory drive and potentially worsen ventilation-perfusion (V/Q) matching, especially in clients with pneumonia.

F.Vital signs every 4 hours: Regular monitoring of vital signs is essential for assessing the client's response to treatment and identifying any signs of deterioration.

G.Continuous pulse oximetry: Continuous pulse oximetry provides real-time monitoring of oxygen saturation and helps assess the effectiveness of oxygen therapy and the client's respiratory status.

H.While a chest x-ray is often indicated for diagnosing pneumonia, ordering it "now" may not be necessary unless the client's condition is unstable or if there are specific concerns regarding the severity of the pneumonia

A. Uncontrollable shaking. B. Throat irritation. C. Increased anxiety. D. Irregular rapid heart beat.

Correct Answer is D

Explanation

D. One of the potential side effects of albuterol is tachycardia (irregular rapid heart beat) due to its stimulatory effects on beta-adrenergic receptors in the heart.

A. While tremors can be distressing for the client, they are generally benign and do not typically require immediate intervention by the nurse.

B. While uncomfortable, throat irritation is generally mild and self-limiting and does not typically require immediate intervention by the nurse.

C. Increased anxiety alone does not typically warrant immediate intervention by the nurse unless it is severe or accompanied by other concerning symptoms.

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Which approach is best for the nurse to use when directing a client with Huntington's disease to the hospital cafeteria?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits What order(s) would the nurse question? (Select all that apply.)

Correct Answer is ["C","E","H"]

Explanation

A client with emphysema reports difficulty breathing and exhibits audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants Immediate intervention by the nurse?

Correct Answer is D

Explanation

Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

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