The nurse is planning care for an older adult client who experienced a cerebrovascular accident several weeks ago. The client has expressive aphasia and often becomes frustrated with the nursing staff. Which intervention should the nurse implement?

Correct Answer: C

Rationale: Encouraging the client's use of picture charts is the most appropriate intervention for a client with expressive aphasia. Picture charts provide visual cues that can aid in communication and reduce frustration for the client. This intervention can help the client express their needs and thoughts effectively. Teaching sign language (Choice A) may be challenging and not as practical in this situation as it may not address the specific communication barriers caused by expressive aphasia. Speaking slowly (Choice B) may not fully address the communication difficulties associated with expressive aphasia. Asking simple questions (Choice D) may not be effective as the client may have difficulty understanding and responding due to the nature of expressive aphasia.

Correct Answer: B

Rationale: The correct answer is B: Pain. Pain is a common and significant symptom of Herpes Zoster (shingles) that can result in difficulty sleeping. The pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. Nocturia (choice C), which is excessive urination during the night, is not directly related to difficulty sleeping in this context. While both frequent cough (choice A) and dyspnea (choice D) can cause sleep disturbances, in a client with Herpes Zoster on the thorax, pain is the most probable cause of sleep difficulty.

Correct Answer: C

Rationale: The priority nursing action for a client diagnosed with acute pyelonephritis is to administer IV antibiotics as prescribed. Acute pyelonephritis is a serious kidney infection that requires prompt antibiotic therapy to prevent systemic complications and worsening of the infection. While monitoring hemoglobin and hematocrit (Choice A) is important, it is not the priority in the acute phase of infection. Encouraging turning and deep breathing (Choice B) and auscultating for bowel sounds (Choice D) are relevant aspects of care but do not take precedence over initiating antibiotic treatment to address the infection promptly.

Correct Answer: C

Rationale: Autonomic dysreflexia is a life-threatening condition commonly seen in clients with spinal cord injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure due to a noxious stimulus below the level of injury, often a distended bladder. The exaggerated sympathetic response leads to vasoconstriction, resulting in symptoms such as profuse diaphoresis (sweating) and a severe, pounding headache. These symptoms are the body's attempt to lower blood pressure. Complaints of chest pain and shortness of breath (Choice A) are not typical findings in autonomic dysreflexia. Hypotension and venous pooling (Choice B) are opposite manifestations of autonomic dysreflexia, which is characterized by hypertension. Pain and burning sensation upon urination and hematuria (Choice D) are indicative of a urinary tract infection and not specific to autonomic dysreflexia.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Rapid weight gain. Prednisone is a corticosteroid medication that can lead to fluid retention and increased appetite, potentially resulting in rapid weight gain. This side effect can be indicative of Cushing's syndrome, a condition associated with prolonged corticosteroid use. It is crucial for the nurse to instruct the client to report rapid weight gain promptly to the healthcare provider to monitor for the development of Cushing's syndrome or other serious complications. Option B) Abdominal striae is incorrect because while it may be a side effect of long-term corticosteroid use, it is not typically a symptom that requires immediate reporting compared to rapid weight gain. Option C) Moon faces is incorrect as well. While moon faces, or the rounding of the face due to fat redistribution, is a common side effect of corticosteroids, it is not as urgent a symptom to report as rapid weight gain. Option D) Gastric irritation is also incorrect. Gastric irritation, such as stomach upset or ulcers, is a common side effect of prednisone but is not as critical to report immediately compared to rapid weight gain, which could indicate more serious complications. Educationally, this question highlights the importance of educating patients about potential side effects of medications, especially corticosteroids like prednisone. Rapid weight gain can be a red flag for significant adverse effects, and prompt reporting to the healthcare provider is essential for timely intervention and management.