The nurse is caring for a client who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse?
Rationale:
Notify the rapid response team (RRT). Rapid intervention is crucial during status epilepticus to prevent further complications. The RRT can provide immediate assistance, ensuring timely administration of emergency medications and supportive care.
A: Administer prescribed carbamazepine. While carbamazepine is an anticonvulsant, it is not the first-line treatment for acute management of status epilepticus, which requires immediate intervention.
C: Obtain a prescription for lorazepam. Lorazepam is essential for treatment, but obtaining a prescription delays immediate administration, which is vital in managing a status epilepticus episode effectively.
D: Loosen any restrictive clothing. Although helpful for comfort, loosening clothing does not address the immediate life-threatening nature of status epilepticus, which requires prompt medical intervention.
E: Review the client's most recent phenytoin level. Checking phenytoin levels is not an immediate action needed during a seizure emergency; addressing the seizure itself takes precedence over laboratory evaluation.
The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?
Rationale:
Planning my activities should help manage the fatigue.
This statement reflects a key understanding of multiple sclerosis management, where pacing activities and incorporating rest can effectively mitigate fatigue, a common and debilitating symptom of the condition.
A: If I experience double-vision, I should put an eye patch on both eyes for a few hours. This approach may worsen visual symptoms rather than providing relief or clarity.
C: I should plan to take a hot bath for my muscle spasms. Heat can exacerbate symptoms in multiple sclerosis, leading to increased discomfort rather than alleviating muscle spasms.
D: This disease may cause me to have an increased sensitivity to pain. While pain can be a symptom, increased sensitivity isn't universally applicable to all patients with multiple sclerosis.
The nurse is supervising a graduate nurse implement seizure precautions for a client with epilepsy. Which observation by the nurse requires follow-up?
Rationale:
Lowering the side rails while the client sleeps requires follow-up. This action increases the risk of injury during a seizure, as the client may fall out of bed unpredictably.
A: Pads the side rails of the bed Enhancing safety by cushioning the side rails helps prevent injury during a seizure, demonstrating a proactive approach to client care.
C: Removes hard and sharp objects from the bed Eliminating potential hazards creates a safer environment for the client, minimizing the risk of injury during seizure activity or postictal state.
E: Places a fall risk bracelet on the client Identifying the client as a fall risk ensures that all staff members are aware of the potential dangers, promoting enhanced monitoring and safety protocols.
The nurse is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
Rationale:
Abrupt onset. Delirium is characterized by a rapid onset of symptoms, distinguishing it from other cognitive disorders. This sudden change can significantly impact an older adult's mental state and functioning.
C: Irreversible. Delirium is typically a reversible condition, contingent upon identifying and addressing its underlying causes, making this choice unsuitable for diagnosis.
D: Progressively worsens. Delirium symptoms can fluctuate rather than follow a progressive decline, thus this option does not align with the nature of the condition.
The nurse is caring for a client with peripheral neuropathy of the lower extremities. Which intervention would be appropriate to prevent injury to the client's feet?
Rationale:
Teach the client about appropriate footwear. Proper footwear is crucial for individuals with peripheral neuropathy to prevent injuries, as it provides necessary protection and support, reducing the risk of skin breakdown and ulcers.
A: Perform Semmes-Weinstein monofilament test. While this test assesses sensory function, it does not directly prevent injury, which is vital for managing peripheral neuropathy effectively.
B: Review the client's most recent blood glucose level. Monitoring blood glucose is important for diabetes management but does not provide immediate strategies to prevent foot injuries in neuropathic patients.
C: Obtain a prescription for gabapentin. Although gabapentin may alleviate neuropathic pain, it does not address the immediate need for protective measures to prevent foot injuries in affected individuals.
The nurse is performing a follow-up assessment on a client who was prescribed carbidopa/levodopa. Which assessment finding would indicate a therapeutic finding from this medication?
Rationale:
A: Decrease in tremors. A reduction in tremors signifies that carbidopa/levodopa is effectively increasing dopamine levels in the brain, which helps alleviate motor symptoms associated with conditions like Parkinson's disease.
B: Improvement in the excessive drooling. This option focuses on saliva management, which is not the primary indication for carbidopa/levodopa, as the medication primarily targets motor symptoms rather than autonomic functions.
C: Reduction in seizure activity. Carbidopa/levodopa does not address seizure disorders; its function centers on enhancing dopamine to manage movement-related symptoms, distinctly separate from seizure control mechanisms.
D: Improvement in muscle spasticity. While muscle spasticity may relate to neurological disorders, carbidopa/levodopa specifically targets tremors and rigidity rather than addressing spasticity, which requires different therapeutic approaches.
The nurse assesses a client with damage to cranial nerve III. Which finding would be expected?
Rationale:
Ptosis. Damage to cranial nerve III, which controls most eye movements and eyelid elevation, typically results in ptosis, characterized by drooping of the eyelid due to weakened muscle function.
B: Anosmia. This condition refers to the loss of smell, linked to cranial nerve I, making it unrelated to cranial nerve III damage and its effects on ocular function.
C: Uvula deviation. Uvula deviation involves cranial nerve IX and X, which control the pharyngeal muscles, thus not associated with cranial nerve III issues affecting eyelid position.
D: Asymmetric facial movement. This symptom pertains to cranial nerve VII, responsible for facial expressions; hence, it does not connect with the dysfunction of cranial nerve III affecting eyelid control.
Which statement below relating to pain and pain perception is accurate?
Rationale:
The perception of pain and its impact on clients vary greatly among individuals. Individual differences in pain thresholds, experiences, and psychological factors contribute to the subjective nature of pain perception, making this statement accurate.
A: Allodynia is the pathophysiological absence of pain when a painful stimulus is applied. Allodynia refers to pain due to stimuli that typically do not provoke pain, not a lack of pain.
B: Scientific evidence does not support the presence of pain during neonatal circumcision. Research indicates that neonates do experience pain during circumcision, contrary to the assertion of a lack of evidence.
C: Hyperalgesia is the opposite of hyperpathia, both of which are abnormal pain responses. Hyperalgesia refers to an increased sensitivity to pain, while hyperpathia is characterized by an exaggerated pain response, not opposites.
The emergency department (ED) nurse cares for a client with a suspected cerebrovascular accident (CVA). Which actions should the nurse take?
Rationale:
Perform a Glasgow coma scale (GCS). The GCS is crucial for assessing the neurological status of a client suspected of having a CVA, helping to determine the level of consciousness and potential severity.
D: Insert a nasogastric tube (NGT). Inserting an NGT is not a priority in the acute assessment of a CVA and does not directly address immediate neurological evaluation needs.
The nurse cares for geriatric clients. The nurse knows which of the following is the leading cause of cognitive impairment in old age?
Rationale:
C: Alzheimer's disease is the leading cause of cognitive impairment in older adults, characterized by progressive memory loss and cognitive decline, significantly impacting daily functioning and quality of life in geriatric clients.
A: Stroke can lead to cognitive impairment but is not the predominant cause in the elderly population, as Alzheimer's disease accounts for a larger percentage of dementia cases.
B: Malnutrition affects overall health and can contribute to cognitive decline; however, it does not specifically lead to the most significant cognitive impairment compared to Alzheimer's disease.
D: Loss of cardiac reserve may impact physical health and function but does not directly lead to cognitive impairment like Alzheimer's disease, which primarily targets cognitive abilities.
The nurse is caring for an older adult client with delirium for the third time in the past four months. While reviewing the client's medical record to determine the cause, the nurse should prioritize reviewing the client's
Rationale:
Current medications should be prioritized for review. Medications can significantly contribute to delirium, especially in older adults, as polypharmacy and side effects are common factors that exacerbate cognitive issues in this population.
A: Vital signs Assessing vital signs, while important, does not directly address potential causes of delirium, which are often linked to medications rather than immediate physiological changes reflected in vital signs.
B: Height and weight Monitoring height and weight provides limited insight into delirium causes, as these factors do not typically correlate with acute changes in mental status or cognitive function in older adults.
C: Family medical history Family medical history may inform predispositions to certain conditions but does not provide immediate, actionable insights into the acute causes of delirium affecting the client currently.
The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
Rationale:
Hourly urine output of 125 mL should be reported to the primary healthcare provider immediately.
This finding indicates potential complications such as diabetes insipidus or altered fluid balance, which are critical following a hypophysectomy. Monitoring urine output is essential post-surgery, as significant deviations can lead to severe electrolyte imbalances and dehydration, necessitating prompt medical intervention.
A: Client reports a decreased smell. This is a common postoperative symptom and not immediately concerning, as it can be temporary following surgery affecting the pituitary gland.
B: No bowel movement in two days. While this may warrant attention, it typically does not require immediate intervention unless accompanied by severe pain or other alarming symptoms.
C: Foul-smelling breath. Although this could indicate an issue, it is not an urgent finding post-hypophysectomy and may be attributed to other non-critical causes.
The nurse is assessing a client with Guillain-Barré syndrome. Which of the following would be an expected finding?
Rationale:
Paresthesia. This symptom is commonly associated with Guillain-Barré syndrome as the condition affects the peripheral nerves, leading to abnormal sensations such as tingling, numbness, or prickling sensations in the limbs.
A: Hyperreflexia. This condition usually results in reduced reflexes due to nerve damage, making hyperreflexia an unlikely finding in patients with Guillain-Barré syndrome.
B: Perseveration. This term refers to the repetition of a particular response or behavior and is not typically associated with the neurological deficits seen in Guillain-Barré syndrome.
C: Dystonia. Characterized by involuntary muscle contractions, dystonia is not a hallmark of Guillain-Barré syndrome, which primarily presents with weakness and sensory disturbances rather than sustained muscle contractions.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 1 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Which of the following assessment findings require immediate follow-up?
Rationale:
Neurological assessment findings require immediate follow-up. Given the client's altered mental state, mumbling, and diaphoretic condition, assessing her neurological status is crucial to identify potential complications or serious conditions, such as infection or drug effects.
B: Pulse and temperature Monitoring these vital signs is important, but they do not demand immediate follow-up compared to neurological changes that may indicate a more critical situation.
C: Gastrointestinal assessment findings Although gastrointestinal symptoms can be significant, they are not as urgent as neurological indicators in this context of altered mental status and infection risk.
D: Influenza vaccination status While relevant to her overall health, the vaccination status does not present an immediate risk that needs urgent assessment compared to her neurological condition.
E: Daily smoking habit This information is not pertinent to her current acute condition, which centers on her neurological status and vital signs rather than long-term lifestyle choices.
F: Blood pressure and pulse oximetry reading Though important, the readings are within reasonable limits and do not indicate immediate danger, unlike the neurological assessment needing urgent attention.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 5 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each physician order, click to specify the appropriate nursing intervention: Lumbar puncture
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Assess the client for an allergy to contrast dye
B
Obtain laboratory work prior to the procedure
C
Position the client flat before the procedure
D
Monitor the client's temperature for efficacy
E
Place an incontinence pad under the client for increased urinary output
F
administer immediately after lumbar puncture
G
establish a patent vascular access device
Rationale:
Obtain laboratory work prior to the procedure. This step is essential to ensure that any underlying conditions or infections are identified before the lumbar puncture, which can prevent complications and guide treatment effectively.
A: Assess the client for an allergy to contrast dye. The scenario does not indicate the use of contrast dye, making this assessment irrelevant to the lumbar puncture preparation.
C: Position the client flat before the procedure. While positioning is important post-lumbar puncture to reduce complications, doing so beforehand is not a necessary nursing intervention in this context.
D: Monitor the client's temperature for efficacy. Temperature monitoring is important for patient safety, but it does not directly relate to the immediate preparation for a lumbar puncture.
E: Place an incontinence pad under the client for increased urinary output. Urinary output management is unrelated to the lumbar puncture procedure and does not address the client's current clinical needs.
F: administer immediately after lumbar puncture. This option doesn't align with the timing of interventions; medication administration should be based on the procedure's outcomes rather than on immediate action.
G: establish a patent vascular access device. This intervention is crucial for medication administration or emergency interventions, ensuring readiness for any immediate needs that arise during or after the procedure.
The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
Rationale:
The client can control the motorized wheelchair. This demonstrates significant progress in physical therapy, as it indicates improved upper body strength, coordination, and the ability to engage with mobility aids effectively, enhancing independence.
B: The client states she wants to stand up with assistance. While this shows motivation, it does not reflect actual physical capability or progress in therapy at this stage.
C: The client says she wants to move her toes. Expressing a desire to move toes indicates hope, but it does not signify any functional improvement or regained mobility after a C6-C7 injury.
D: The client says she regained her bladder control. Regaining bladder control is a crucial aspect of recovery, but it does not directly relate to mobility or physical therapy progress in this context.
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
Rationale:
B: Instruct the client to turn their head from side to side.
This intervention helps the client compensate for their visual field loss by promoting scanning techniques. It encourages awareness of their surroundings, enhancing safety and mobility, which is crucial for individuals with homonymous hemianopia.
A: Place an eye patch over the affected eye.
Using an eye patch does not address the visual field deficit caused by homonymous hemianopia and may further limit the client's visual capabilities instead of providing a solution.
C: Speak slowly, clearly, and in a deeper voice.
Communication methods such as altering voice tone or speed do not directly assist in the visual impairments associated with homonymous hemianopia and are irrelevant to the client's primary needs.
D: Provide the client with ear plugs to promote rest.
Ear plugs are intended for noise reduction and do not relate to the client's visual challenges. This intervention fails to address the necessary adaptations for managing homonymous hemianopia effectively.
The nurse is caring for a client with a concussion. Which assessment finding indicates that the client is experiencing a complication?
Rationale:
Heart rate 56 indicates that the client is experiencing a complication. A significantly low heart rate can suggest increased intracranial pressure or other serious neurological issues requiring immediate medical attention.
A: Reports of a persistent headache Persistent headaches can occur following a concussion, but they typically do not indicate a severe complication unless accompanied by other alarming symptoms.
B: Glasgow Coma Scale 13 A Glasgow Coma Scale score of 13 is still within acceptable limits and does not suggest a severe worsening of the client’s condition.
D: Drowsiness While drowsiness can be concerning, it may not necessarily indicate a severe complication. It’s important to evaluate other symptoms for a comprehensive assessment.
Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain?
Rationale:
Neuropathic pain can arise from conditions that directly affect nerve function. Both spinal tumors and shingles disrupt nerve pathways, leading to pain that is distinct from nociceptive sources, making them recognized potential sources of neuropathic pain.
B: Arthritic joint Primarily involves inflammatory pain resulting from joint degeneration rather than direct nerve damage, categorizing it as nociceptive pain instead of neuropathic.
C: Muscle strain Typically causes musculoskeletal pain due to soft tissue injury, not involving nerve pathways directly, and therefore does not qualify as a source of neuropathic pain.
E: Kidney stones Cause acute, intense pain due to obstruction in the urinary tract, but this pain is classified as visceral pain rather than neuropathic, which is related to nerve irritation.
The nurse is assessing a client with suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
Rationale:
Diaphoresis is a finding that would support a diagnosis of neurogenic shock. This condition often leads to loss of sympathetic tone, resulting in decreased vascular resistance and compensatory sweating as the body attempts to regulate temperature and maintain homeostasis despite hypotension.
A: Respiratory acidosis does not support neurogenic shock; it typically indicates a respiratory issue rather than a neurological one, which is the primary concern in neurogenic shock.
B: Thready peripheral pulses indicate hypovolemia or cardiac issue rather than neurogenic shock, where pulses may be normal or bounding due to vasodilation and hypotension.
D: Polyuria suggests a renal response to fluid imbalance or diabetes insipidus, which does not align with the symptoms and physiological changes seen in neurogenic shock.
A client presents to the emergency department with symptoms of muscle weakness, double vision, and difficulty swallowing. The nurse suspects botulism poisoning. Which of the following statements accurately describes botulism?
Rationale:
Botulism toxin inhibits the release of acetylcholine at neuromuscular junctions. This mechanism leads to paralysis and muscle weakness, aligning with the client's symptoms of double vision and difficulty swallowing, typical of botulism.
A: Botulism is caused by a bacterial infection with Clostridium difficile. Clostridium difficile primarily leads to gastrointestinal issues, not the neuroparalytic effects seen in botulism caused by Clostridium botulinum.
B: Botulism is primarily transmitted through contaminated water sources. The primary transmission route for botulism is through improperly canned or preserved foods, not via water sources.
C: Botulism toxin acts by enhancing muscle contractions and reflexes. In contrast, botulism toxin disrupts neurotransmission, resulting in reduced muscle activity, not enhanced contractions or reflexes.
The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?
Rationale:
A: Prepares to administer intravenous valproate. Administering intravenous valproate in status epilepticus is inappropriate as it is not the first-line treatment; benzodiazepines should be prioritized for immediate seizure control in this critical situation.
B: Place the client in a lateral position. Positioning the client laterally is a standard practice to prevent aspiration and ensure airway patency during seizures, promoting safety and effective care.
C: Activates the rapid response team (RRT). Activating the RRT is a proactive measure that ensures timely assistance and intervention in a critical scenario, aiding in the management of the client's condition.
D: Loosens any restrictive clothing. Loosening restrictive clothing helps facilitate breathing and circulation, minimizing risk during a seizure and providing necessary comfort to the client during the episode.
A 28-year-old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but cannot move the right. However, she cannot feel any pain in her left. The nurse knows these symptoms suggest which type of spinal cord injury?
Rationale:
B: Incomplete spinal cord injury, Brown-Sequard syndrome. This condition typically results from a unilateral spinal cord lesion, leading to motor function loss on one side and sensory deficits on the opposite side, as seen in this patient.
A: Incomplete spinal cord injury, central cord syndrome. This syndrome primarily affects upper limb motor function more than lower limbs, which does not align with the presented symptoms of asymmetric motor loss.
C: Complete spinal cord injury, paraplegia. Complete injuries result in total loss of function below the injury level, contradicting the ability to move the left side of the body observed in this case.
D: Incomplete spinal cord injury, anterior cord syndrome. This syndrome causes loss of pain and temperature sensation below the injury but typically preserves proprioception, which doesn't match the patient's sensory experience.
The nurse is performing medication reconciliation for a client with Parkinson's disease. Which medication should the nurse question with the primary healthcare provider (PHCP)?
Rationale:
Haloperidol should be questioned with the primary healthcare provider (PHCP). This antipsychotic medication can exacerbate Parkinson's disease symptoms due to its dopamine-blocking effects, potentially leading to worsening motor function and increased rigidity in patients already struggling with these issues.
B: Levodopa-carbidopa is a primary treatment for Parkinson's disease, effectively managing motor symptoms by replenishing dopamine levels, making it essential for patient care.
C: Pramipexole serves as a dopamine agonist, stimulating dopamine receptors and improving motor function in Parkinson's patients, thus supporting overall treatment strategies.
D: Ropinirole, another dopamine agonist, provides symptomatic relief in Parkinson's disease by mimicking dopamine's effects, making it a valuable component of the patient's medication regimen.
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
Rationale:
Angina. This symptom indicates potential cardiovascular complications associated with sumatriptan, such as coronary vasospasm. The presence of angina suggests the drug may be adversely affecting the client’s heart, warranting further evaluation.
A: Nervousness. This can arise from various factors, including anxiety or caffeine intake, and does not specifically relate to the pharmacological effects of sumatriptan, making it an unreliable indicator of adverse effects.
B: Warm sensation. Often considered a common and benign effect of sumatriptan, a warm sensation does not signify a serious adverse response, but rather a typical physiological reaction to the medication.
D: Tingling sensation. While tingling can occur with sumatriptan use, it is generally not alarming and may indicate normal drug effects, rather than a specific adverse response warranting concern or intervention.
The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
Rationale:
The client’s VPA level is 40 mcg/mL, which is below the therapeutic range of 50-125 mcg/mL, indicating a potential issue with medication adherence that the nurse should evaluate.
A: Evaluate the client for non-adherence. This option is appropriate as the low VPA level suggests the possibility that the client may not be taking the medication as prescribed.
B: Instruct the client to skip the next scheduled dose. Skipping a dose could further lower the VPA level and exacerbate seizure activity, contradicting treatment objectives.
C: Assess the client for VPA toxicity. A level of 40 mcg/mL is below the therapeutic range and does not indicate toxicity, so this assessment is unnecessary.
D: Document the result as within normal limits. The VPA level is below the therapeutic range, rendering this documentation misleading and potentially harmful to the client’s treatment plan.
The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply.
Rationale:
Topiramate and Lorazepam are anticipated prescriptions for a client diagnosed with epilepsy due to their effectiveness in managing seizures. Topiramate is an anticonvulsant, while Lorazepam provides rapid seizure control during acute episodes.
B: Risperidone is an antipsychotic medication primarily used to treat mood disorders and schizophrenia, not seizures.
C: Prazosin is mainly indicated for hypertension and PTSD-related nightmares, lacking efficacy in seizure management.
D: Hydroxyzine serves as an antihistamine and anxiolytic, not an appropriate choice for treating epilepsy.
The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
Rationale:
Respiratory acidosis requires follow-up with the physician prior to administering midazolam due to the medication's potential to further depress respiratory function, which could exacerbate the client’s condition and lead to serious complications.
A: Cocaine intoxication may cause agitation or altered mental status, but does not inherently contraindicate midazolam use. Monitoring and clinical judgment are essential in such scenarios.
C: Tonic-clonic seizures often require immediate intervention, and midazolam can be indicated for seizure management, thus making this option not a reason for follow-up.
D: Aggression does not pose a direct risk concerning midazolam administration. The nurse can address behavioral issues while still safely administering the medication as needed.
The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider?
Rationale:
Modafinil is the anticipated prescription for a client with narcolepsy. This medication promotes wakefulness and is specifically approved for treating excessive daytime sleepiness associated with narcolepsy, making it the most suitable choice.
A: Trazodone This medication primarily addresses insomnia and depression, lacking the specific wakefulness-promoting properties necessary for managing narcolepsy effectively.
C: Diazepam Primarily used for anxiety and muscle relaxation, diazepam can lead to sedation, which would exacerbate symptoms of narcolepsy rather than alleviate them.
D: Fluoxetine As an SSRI for depression, fluoxetine does not target the symptoms of narcolepsy and may not provide any benefit for excessive daytime sleepiness.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 2 of 6
History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
The nurse recognizes that which of the following conditions may feature photophobia? Select all that apply.
Rationale:
Migraine headache and meningitis may feature photophobia.
Migraine headaches are commonly associated with photophobia due to the intense pain and sensitivity to light experienced during episodes. Similarly, meningitis can lead to photophobia as a result of inflammation of the protective membranes surrounding the brain, causing heightened sensitivity to light and discomfort.
B: Guillain-Barré syndrome does not typically involve photophobia; it primarily affects the peripheral nervous system, leading to muscle weakness and sensory changes, but not light sensitivity.
D: Delirium is characterized by confusion and altered mental status, but photophobia is not a hallmark symptom; it does not directly interfere with light perception.
E: Alzheimer's disease is primarily associated with cognitive decline and memory loss rather than light sensitivity; photophobia is not a recognized symptom of this condition.
F: Parkinson's disease does not commonly present with photophobia; its symptoms revolve around movement difficulties and tremors rather than sensitivity to light.
The nurse is performing medication reconciliation for a client with Parkinson's disease. Which medication should the nurse question with the primary healthcare provider (PHCP)?
Rationale:
Haloperidol should be questioned with the primary healthcare provider. This antipsychotic can exacerbate Parkinson's symptoms and lead to severe side effects, making it inappropriate for a patient already dealing with this neurological condition.
B: Levodopa-carbidopa This medication is a standard treatment for Parkinson's disease, effectively managing symptoms and improving motor function without causing adverse reactions typically associated with antipsychotics.
C: Pramipexole As a dopamine agonist, pramipexole helps alleviate Parkinson's symptoms by stimulating dopamine receptors, making it beneficial for patients and aligning with their treatment goals.
D: Ropinirole Similar to pramipexole, ropinirole serves as a dopamine agonist that enhances motor control in Parkinson's disease patients, providing symptomatic relief and improving overall quality of life.
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
Rationale:
C: Angina indicates an adverse response to sumatriptan, as this medication is a vasoconstrictor that can potentially strain the cardiovascular system. Experiencing chest pain suggests a serious reaction requiring immediate assessment and intervention.
A: Nervousness might occur due to the medication's stimulant effects but does not signify a severe adverse response. It is a relatively common side effect and often manageable.
B: Warm sensation can be a normal reaction to sumatriptan, reflecting its mechanism of action on blood vessels. This sensation typically doesn't indicate significant harm or concern for the client.
D: Tingling sensation is often a benign side effect associated with sumatriptan, related to nerve stimulation rather than a dangerous reaction. It usually resolves without further complications or intervention.
The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
Rationale:
Evaluate the client for non-adherence. A VPA level of 40 mcg/mL is below the therapeutic range of 50-125 mcg/mL, indicating the possibility that the client may not be taking the medication as prescribed.
B: Instruct the client to skip the next scheduled dose. Skipping a dose is not appropriate; the low level suggests a need for medication adherence rather than omission.
C: Assess the client for VPA toxicity. A level of 40 mcg/mL does not indicate toxicity, as it falls significantly below the therapeutic range required for effective seizure management.
D: Document the result as within normal limits. The result is below the normal therapeutic range, necessitating further action instead of simply documenting it as acceptable.
The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply.
Rationale:
Topiramate and Lorazepam are commonly prescribed medications for managing epilepsy. Topiramate is an anticonvulsant effective in seizure control, while Lorazepam is used for its rapid anticonvulsant properties during seizures.
B: Risperidone Antipsychotic medication primarily used for mental health disorders, not indicated for seizure management or epilepsy treatment.
C: Prazosin Primarily prescribed for hypertension and PTSD, lacking relevance to seizure control or epilepsy management.
D: Hydroxyzine An antihistamine used for anxiety and allergies, not effective for treating seizures or epilepsy.
The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
Rationale:
B: Respiratory acidosis is a critical condition that may impair respiratory function, increasing the risk of respiratory depression when midazolam, a sedative, is administered. This warrants immediate communication with the physician to ensure patient safety.
A: Cocaine intoxication presents a different set of risks, primarily related to cardiovascular effects rather than respiratory complications, making it less urgent for follow-up prior to midazolam administration.
C: Tonic-clonic seizures indicate a need for treatment, and midazolam is often used to manage seizures. This situation does not inherently necessitate physician consultation before administering the medication.
D: Aggression may indicate underlying psychological issues, but it does not pose an immediate physiological risk when considering the administration of midazolam, thus not requiring prior follow-up with the physician.
The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider?
Rationale:
Modafinil is the prescription the nurse anticipates for a client with narcolepsy. This medication is a wakefulness-promoting agent specifically effective in managing excessive daytime sleepiness associated with narcolepsy, enhancing alertness and cognitive function.
A: Trazodone A sedative primarily used for depression and insomnia, it does not address the core symptoms of narcolepsy, which include excessive daytime sleepiness and sudden sleep attacks.
C: Diazepam A benzodiazepine that provides sedation and muscle relaxation, it may exacerbate sleepiness rather than alleviate it, making it unsuitable for treating narcolepsy's primary symptoms.
D: Fluoxetine An SSRI for depression and anxiety, it does not target narcolepsy's excessive daytime sleepiness and is not indicated for this specific sleep disorder management.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 2 of 6
History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
The nurse recognizes that which of the following conditions may feature photophobia? Select all that apply.
Rationale:
Migraine headache and meningitis may feature photophobia.
Migraine headaches are characterized by intense, throbbing pain often accompanied by visual disturbances and photophobia, as seen in the client's symptoms. Meningitis, an inflammation of the protective membranes of the brain, also frequently presents with photophobia due to irritation of the meninges and increased sensitivity to light.
B: Guillain-Barré syndrome primarily affects nerves and muscle strength, lacking the visual disturbances and sensitivity to light typically associated with photophobia.
D: Delirium involves cognitive changes and altered consciousness, but it does not specifically cause photophobia as a common symptom.
E: Alzheimer's disease primarily affects memory and cognitive function, with photophobia not being a characteristic feature of the condition.
F: Parkinson's disease is centered on motor control and rigidity, with light sensitivity like photophobia not being a noted symptom in this disorder.
The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?
Rationale:
A: Confusion indicates a change in mental status as it often arises from underlying health issues, including infections like pneumonia, particularly in elderly clients, reflecting cognitive impairment or distress.
B: Disorientation signifies confusion about time, place, or identity, which can also suggest mental status changes but lacks the broader implications of overall cognitive impairment associated with confusion.
C: Agitation may reflect anxiety or distress but does not specifically indicate cognitive impairment; it could arise from various factors unrelated to mental status changes.
D: Delirium represents an acute alteration in cognition, yet it is more specific than confusion and may not encompass all aspects of mental status changes seen in elderly patients.
E: Hypervigilance involves an exaggerated state of alertness, which may not directly indicate a decline in cognitive function, focusing instead on heightened awareness rather than mental status alterations.
The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Obtain an accurate weight
B
Insert two peripheral vascular access devices
C
Insert a nasogastric tube (NGT) immediately after alteplase infusion
D
Obtain baseline laboratory work (CBC, CMP, aPTT, PT/INR) prior to infusion of alteplase
E
Plan for admission to the medical-surgical floor
F
Perform frequent neurological assessments
G
Notify the physician if the systolic blood pressure is 185 mm Hg or greater
Rationale:
Obtain an accurate weight. This intervention is essential to ensure the correct dosing of alteplase, as the medication dosage is calculated based on the patient's weight. Accurate weight measurement is a key factor in medication safety and efficacy.
B: Insert two peripheral vascular access devices. This is excessive; one peripheral access is generally sufficient for the administration of IV medications like alteplase.
C: Insert a nasogastric tube (NGT) immediately after alteplase infusion. NGT insertion could increase the risk of bleeding, especially after alteplase administration, which is contraindicated.
E: Plan for admission to the medical-surgical floor. Admission planning is premature without stabilizing the client first, as further evaluation and monitoring are required post-infusion.
F: Perform frequent neurological assessments. While monitoring is crucial, the frequency of assessments must be based on the physician's orders and patient stability, not a standard intervention.
G: Notify the physician if the systolic blood pressure is 185 mm Hg or greater. This is a standard intervention but does not directly relate to the immediate care plan for alteplase.
The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?
Rationale:
Periorbital ecchymosis indicates possible cerebrospinal fluid leakage or vascular injury, which necessitates immediate evaluation. This finding may signify serious complications associated with basilar skull fractures, making prompt intervention critical for patient safety.
C: Temperature 100.9°F (38.3°C) Mild fever can occur in various conditions, but it does not specifically indicate a critical complication related to basilar skull fractures that requires urgent attention.
D: Headache While headache can be a common symptom following a skull fracture, it does not inherently signify an emergency requiring immediate follow-up in the context of basilar skull injuries.
A 30-year-old man was involved in a head-on collision and was unconscious for two minutes prior to EMS arrival. Five minutes before arriving at the hospital, the paramedic notices clear fluid draining from the patient's nose. Having seen this before, the paramedic places a drop from the patient's nose onto a piece of gauze. The nurse is looking for a clinical finding that is called the halo's sign. What type of fracture does the paramedic suspect the patient has?
Rationale:
A basilar skull fracture is suspected. The presence of clear fluid draining from the nose indicates cerebrospinal fluid, which often occurs with a basilar skull fracture, suggesting significant trauma to the cranial base.
A: Depressed skull fracture. This type of fracture typically involves a portion of the skull being pushed inward, not associated with clear fluid drainage from the nose.
B: Traumatic linear skull fracture. While it can occur from trauma, this fracture type does not usually result in the leakage of cerebrospinal fluid, which is a key sign here.
C: Subarachnoid hemorrhage. This condition involves bleeding in the space between the brain and the tissues covering it, which does not correlate with the clear fluid observed in this scenario.
The nurse is caring for an older adult with advanced dementia. The client asks about her deceased sister, 'When will my sister come to visit me this afternoon?' Which is the best response from the nurse?
Rationale:
C: I understand you want her to visit you. Where did you and your sister grow up? This response validates the client's feelings while gently redirecting the conversation, fostering connection and engagement without causing distress about the sister's absence. It respects the client's emotional state and encourages reminiscence, which can be comforting for someone with advanced dementia.
A: This is so sad. I'm sorry to tell you but your sister died last year. This response is overly blunt and may cause unnecessary emotional pain, undermining the client's comfort.
B: She won't be coming to visit today. This response lacks empathy and fails to engage with the client's feelings, potentially heightening their distress and confusion regarding their sister's absence.
D: Wait and see if she comes to visit today. This response is ambiguous and may lead to further confusion or disappointment, as it does not address the reality of the situation.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
Rationale:
A, B, D: Presbycusis, ototoxic substances, and exposure to loud noise are established contributors to sensorineural hearing loss. These factors damage the inner ear or auditory pathways, leading to permanent hearing impairment over time.
C: Foreign body This option pertains to conductive hearing loss, as foreign objects typically block sound transmission rather than causing inner ear damage.
E: Edema This choice relates to fluid accumulation, which may affect hearing temporarily but does not directly lead to sensorineural hearing loss in established contexts.
The nurse is caring for a client who sustained an ischemic cerebrovascular accident (CVA) three hours ago. The client's most recent blood pressure was 168/101 mm Hg. The nurse should take which action?
Rationale:
Continue to monitor the client.
Monitoring is crucial after an ischemic CVA to assess neurological status and blood pressure fluctuations, ensuring timely intervention if the client's condition worsens. Continuous observation helps detect complications early, which is vital for optimal recovery.
A: Position the head of the bed completely flat. This position can impede cerebral blood flow and increase intracranial pressure, potentially worsening the client's condition after a CVA.
C: Obtain orthostatic blood pressure. While important in some scenarios, it does not address immediate concerns related to the client's recent CVA and elevated blood pressure, which requires ongoing monitoring instead.
D: Request a prescription for an antihypertensive. This action may be premature without further assessment of the patient's neurological status and blood pressure trends, as immediate treatment decisions must be based on monitoring.
The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected?
Rationale:
Chorea and weight loss are expected assessment findings in a client with Huntington's disease. Chorea involves involuntary movements, while weight loss can occur due to difficulties with swallowing and decreased appetite.
A: Halitosis Poor oral hygiene or dry mouth may lead to halitosis; however, this symptom is not directly associated with Huntington's disease and its neurological manifestations.
C: Hallucinations While psychiatric symptoms can occur, hallucinations are not a primary characteristic of Huntington's disease and are more commonly linked to other mental health disorders.
D: Hematemesis This symptom indicates gastrointestinal bleeding, which is not a typical feature of Huntington's disease and suggests other medical conditions unrelated to the neurodegenerative disorder.
E: Weight loss Weight loss is indeed a common symptom associated with Huntington's disease, stemming from metabolic changes and challenges in eating, making it a relevant finding in this context.
The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following?
Rationale:
The client is demonstrating signs of agnosia. Agnosia refers to the inability to recognize familiar objects or people, which aligns with the client not recognizing their family member due to dementia's cognitive impairments.
A: Apraxia involves difficulty with motor planning and executing tasks, not a failure to recognize familiar individuals. This does not apply to the client's situation.
B: Agraphia is the inability to write, which does not relate to recognition issues or the specific cognitive challenges faced by the client.
D: Aphasia affects language production or comprehension, rather than recognition abilities. The client’s failure to identify a family member is more aligned with agnosia.
Select the three (3) prescriptions/orders the nurse should anticipate for this client
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Computed tomography scan of the brain
B
Capillary blood glucose
C
Lumbar puncture
D
Arterial blood gas (ABG)
E
Heparin by continuous IV infusion
F
Nothing by mouth (NPO) status
G
500 mL of 0.9% saline
Rationale:
Computed tomography scan of the brain, capillary blood glucose, and nothing by mouth (NPO) status are the anticipated prescriptions/orders for this client.
The CT scan evaluates potential intracranial issues, the capillary blood glucose checks for hypoglycemia, and NPO status prevents complications during tests or procedures. These interventions are vital for ensuring accurate diagnosis and patient safety.
C: Lumbar puncture This procedure is typically reserved for diagnosing infections or neurological conditions rather than initial assessments, making it less relevant in this context.
D: Arterial blood gas (ABG) This test primarily assesses respiratory function and acid-base balance, which may not be immediately necessary given the focus on neurological evaluation and glucose monitoring.
E: Heparin by continuous IV infusion Administering anticoagulants like heparin is not warranted initially, especially when the primary concerns involve imaging and glucose levels rather than thromboembolic events.
G: 500 mL of 0.9% saline Administering saline is not prioritized in this scenario, as the focus should remain on diagnostic imaging and monitoring blood glucose levels without unnecessary hydration.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
Rationale:
Sensorineural hearing loss can be caused by diabetes mellitus, Meniere's disease, and exposure to loud noise. These factors lead to damage in the inner ear or auditory nerve pathways, affecting sound transmission.
C: Excessive cerumen This condition typically results in conductive hearing loss due to blockage in the ear canal, rather than damage to the inner ear structures associated with sensorineural loss.
E: Excessive fluid Fluid accumulation may lead to conductive hearing loss by impacting eustachian tube function and middle ear pressure, not directly affecting the inner ear or auditory processing.
The nurse is assessing a client with suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
Rationale:
Bradycardia indicates a decrease in heart rate, which is a hallmark of neurogenic shock due to disrupted autonomic regulation. This finding supports the diagnosis as it reflects the loss of sympathetic tone and unopposed vagal activity typical in such shock scenarios.
A: Jugular vein distention does not align with neurogenic shock, which typically presents with hypotension and bradycardia rather than signs of fluid overload or increased central venous pressure.
C: Fever does not correlate with neurogenic shock, as this condition is characterized by hypothermia or normal temperature, not elevated body temperatures indicating infection or inflammation.
D: Bradypnea is not a defining feature of neurogenic shock, which primarily affects heart rate and blood pressure. Respiratory rate alterations typically relate to other underlying conditions rather than neurogenic mechanisms.
A nurse is caring for a client with a history of seizures who is at risk for injury. Which intervention is the highest priority to reduce the client's risk of injury?
Rationale:
Implement seizure precautions, including padded side rails up and the bed in the lowest position. This intervention directly addresses the immediate risk of injury during a potential seizure, ensuring the client’s safety.
A: Keeping the client's room dimly lit to minimize visual stimulation. While reducing visual stimulation can be beneficial, it does not directly prevent injuries that may occur during a seizure.
B: Administer antiepileptic medications as prescribed. Although medication management is crucial for seizure control, it does not provide immediate protection against injury during an active seizure episode.
D: Provide education to the client and family about seizure triggers and safety measures. Education is important for long-term management but does not offer direct and immediate protection during a seizure event.