The nurse is completing an admission interview and
assessment on a client with a history of Parkinson's
disease. Which question should provide information
relevant to the client's plan of care?
Have you ever experienced any paralysis of your
arms or legs?
Have you ever sustained a severe head injury?
Have you ever been 'frozen' in one spot, unable to
move?
Do you have headaches, especially ones with
throbbing pain? - ...ANSWER...Have you ever been
'frozen' in one spot, unable to move?
RATIONALE: Clients with Parkinson's disease
frequently experience difficulty in initiating,
maintaining, and performing motor activities. They may
even experience being rooted to the spot and unable
to move (C). Parkinson's disease does not cause (A).
Parkinson's disease is not usually associated with (B),
nor does it typically cause (D)
A 58-year-old client, who has no health problems, asks
the nurse about the Pneumovax vaccine. The nurse's
response to the client should be based on which
information?
The vaccine is given annually before the flu season to
those over 50 years of age.
The immunization is administered once to older adults
or persons with a history of chronic illness.
The vaccine is for all ages and is given primarily to
those persons traveling overseas to areas of infection.
The vaccine will prevent the occurrence of
pneumococcal pneumonia for up to five years. -
...ANSWER...B) The immunization is administered
once to older adults or persons with a history of
chronic illness.
RATIONALE: It is usually recommended that persons
over 65 years of age and those with a history of
chronic illness receive the vaccine once in a lifetime
(B). (Some resources recommend obtaining the
vaccine at 50 years of age.) The influenza vaccine is
given once a year, not the Pneumovax (A). Although
the vaccine might be given to a person traveling
overseas, that is not the main rationale for
administering the vaccine (C). It is usually given once
in a lifetime (D), but with immunosuppressed clients or
clients with a history of pneumonia re-vaccination is
sometimes required.
Which reaction should the nurse identify in a client who
is responding to stimulation of the sympathetic nervous
system?
Pupil constriction.
Increased heart rate.
Bronchial constriction.
Decreased blood pressure. - ...ANSWER...B)
Increased heart rate.
RATIONALE: Any stressor that is perceived as
threatening to homeostasis acts to stimulate the
sympathetic nervous system and manifests as a flightor-fight response, which includes an increase in heart
rate (B). (A, C, and D) are responses of the
parasympathetic nervous system.
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