NR-325 Adult Health II - Set 3 - Part 3

Correct Answer: Suction the mouth with the client side-lying

Gurgling means secretions and vomit sit in the pharynx. Clearing them with the client side-lying restores a patent airway, and airway always outranks glucose testing, injury survey and drug administration. Option a is incorrect because benzodiazepines treat continuing seizure activity, and this seizure has already ended. Giving one now adds sedation and respiratory depression to a client whose airway is already compromised. Option b is incorrect because glucose testing does belong in postictal care, since low sugar both causes and follows prolonged seizures. A finger stick still waits until the pharynx is clear and breathing is quiet. Option c is incorrect because a full injury survey is essential later, once ventilation is secure. Fractures, dental damage and shoulder dislocation are found by that examination, but none of them threatens breathing right now.

Correct Answer: Pressure inside the skull is stimulating the medulla

Vomiting that arrives without nausea is a classic marker of raised intracranial pressure, sometimes projectile. Pressure changes in the cranium stimulate the vomiting center directly and bypass the usual nausea pathway. Option b is incorrect because food intolerance builds queasiness first and then brings the emesis. The missing nausea is exactly the detail that separates a stomach complaint from a neurologic red flag. Option c is incorrect because worry produces churning discomfort long before anything comes up. Assigning this episode to emotion would delay the neurologic reassessment and the report the finding actually deserves. Option d is incorrect because a brisk gag triggers retching only when the throat is touched, and nothing touched it here. An overactive reflex also fails to explain emesis that erupts with no lead-up.

Correct Answer: Turning the client every two hours

Turning on a schedule is a standard task assistive personnel perform once the nurse has set the plan. Range of motion, hygiene, intake and output, and vital signs sit in the same category. Option a is incorrect because deciding whether redness blanches is a skin assessment with a staging decision behind it. Assistive personnel report what they see and the nurse interprets the finding. Option b is incorrect because client and family teaching stays with the licensed nurse. Explaining why the insensate side needs checking, and confirming that the family understood, requires evaluation no aide is licensed to perform. Option c is incorrect because starting a timed voiding program flows from assessment of retention, fluid pattern, and continence history. That planning belongs to the nurse, who then tells the aide when to toilet the client.

Correct Answer: "I will turn the television off and ask yes or no questions."

Cutting the background noise and asking questions that take a yes or a no gives a client with aphasia a channel that still works. Both strategies come straight from the nursing plan. Option a is incorrect because loudness treats aphasia as deafness. Hearing is usually intact, so raising the voice only signals impatience and can leave the client feeling talked down to at home. Option c is incorrect because completing his sentences removes the very practice that rebuilds language. Kindly meant as it is, the habit teaches the client to stop trying and hands the conversation to someone else. Option d is incorrect because faking comprehension invites mistakes about pain, hunger, and safety. A spouse who nods without understanding will eventually act on a message that was never actually sent.

Correct Answer: An absence seizure

Absence seizures last under ten seconds, start and stop abruptly, and leave no confusion behind, so the client picks up mid sentence. Subtle eyelid flutter is the classic accompanying movement. Option b is incorrect because myoclonic events are single shock-like jerks of the arms or shoulders lasting a fraction of a second. They cluster on waking and involve movement, not a blank pause. Option c is incorrect because a convulsion of that kind brings a cry, a fall, stiffening and jerking for one to three minutes. Deep postictal sleep would follow, which the spouse did not describe. Option d is incorrect because atonic seizures dump muscle tone suddenly, so the head drops or the knees give way and the client hits the floor. Falling is the whole picture, and injury risk is highest.

Correct Answer: Expressive aphasia from a frontal lesion

Broca or expressive aphasia leaves comprehension largely intact while wrecking output. The client knows the words, cannot assemble them, and hears the mistakes, which is why frustration and tears run so high in this form. Option a is incorrect because Wernicke aphasia runs the opposite way. Speech pours out fluently with wrong or invented words, comprehension is damaged, and the client usually has no idea anything is amiss. Option b is incorrect because global involvement wipes out understanding as well as expression. This client carries out instructions without difficulty, which rules out the comprehension loss that defines the global form. Option d is incorrect because slurred speech from weak muscles is a motor problem, not a language one. A client with dysarthria can still choose words normally and can write a perfectly formed sentence.

Correct Answer: A wet gurgly voice heard after each swallow

A wet gurgly voice means secretions or food are sitting on the vocal cords, which is the bedside signature of material entering the airway. Feeding stops and the client is reassessed before anything else. Option a is incorrect because tiredness at the end of a meal is common early after a stroke and reflects the effort of chewing. It calls for shorter meals and rest, not an interrupted tray. Option c is incorrect because choosing softer items over minced meat is a taste and comfort preference. Nothing about it indicates that the bolus is escaping into the larynx, so the meal can safely continue. Option d is incorrect because reduced appetite after a stroke stems from fatigue, altered taste, and depression. That pattern deserves calorie counts and a dietitian referral rather than an immediate halt to feeding.

Correct Answer: Weakness on the right side with aphasia

Motor pathways cross in the brainstem, so a left hemisphere lesion weakens the right side. The dominant language centers also sit on the left in nearly everyone, which adds aphasia to the picture. Option b is incorrect because left sided weakness follows a right hemisphere lesion, and neglect belongs to that same non dominant side. The lesion here sits on the left, so the body findings appear on the right. Option c is incorrect because bilateral weakness suggests a brainstem or spinal process rather than a single hemispheric infarct. One middle cerebral artery supplies only one hemisphere, so the deficit stays confined to the opposite half of the body. Option d is incorrect because it puts the motor loss on the wrong side. Aphasia does point to the left hemisphere, but a left hemisphere infarct paralyzes the right limbs, not the left ones.

Correct Answer: Ask the client directly about thoughts of suicide

A statement like that is screened, not soothed. Asking plainly about suicidal thinking establishes immediate risk, and safety outranks every other part of the rehabilitation plan until the answer is known. Option a is incorrect because reassurance closes a conversation the client has just opened. Optimism about the timeline skips over the withdrawal, poor appetite, and hopelessness that together suggest post-stroke depression. Option b is incorrect because a meeting scheduled for later in the week does nothing about tonight. Family involvement matters in recovery, but it cannot substitute for an immediate assessment of danger. Option c is incorrect because charting a remark of this weight and moving on treats it as routine. Depression after stroke worsens functional recovery, and an expression of hopelessness demands a direct response now.

Correct Answer: Ask simple questions and allow generous answering time

Language is impaired, not hearing or intelligence. Short simple questions the client can answer with a yes or a no, plus unhurried time to produce the words, keep the exchange working. Option a is incorrect because volume does nothing for a language deficit and reads as condescension. Shouting at an adult who understands every word damages the relationship and often deepens the frustration already present. Option b is incorrect because supplying the ending strips away the effort the client is making and the practice that rebuilds speech. Waiting through the silence is harder for the nurse than for the client. Option d is incorrect because pretending to follow a message destroys trust the moment the client realizes it. Asking for a repeat, a gesture, or a picture is honest and prevents a serious misunderstanding.