The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 22-year-old female.
Item 1 of 1
History And Physical Orders
1114: A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation.
For each physician order, click to specify the appropriate nursing intervention: Magnetic Resonance Imaging (MRI) of the brain
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Ensure the client has a negative pregnancy test prior to the exam
B
Assess if the client has claustrophobia prior to the exam
C
Have the client nothing by mouth (NPO) eight hours prior to the exam
D
Monitor the client's lung sounds for pulmonary edema
E
Establish continuous cardiac monitoring during the infusion
F
Insert an indwelling urinary catheter to monitor intake and output
G
Position the client side-lying with their knees to their chest
Rationale:
Ensure the client has a negative pregnancy test prior to the exam. This is essential since MRI scans can pose risks to a developing fetus, necessitating confirmation of non-pregnancy before proceeding with imaging.
B: Assess if the client has claustrophobia prior to the exam. While important, this step does not directly relate to pre-exam safety or contraindications for the MRI procedure.
C: Have the client nothing by mouth (NPO) eight hours prior to the exam. The scenario does not indicate that the MRI requires fasting, making this unnecessary for the client.
D: Monitor the client's lung sounds for pulmonary edema. This intervention is not relevant to the MRI process and does not address any immediate concerns related to the patient's condition.
E: Establish continuous cardiac monitoring during the infusion. While critical in some scenarios, this does not pertain to the MRI preparation and is not standard for imaging procedures.
F: Insert an indwelling urinary catheter to monitor intake and output. This is not a typical requirement for an MRI and does not relate to imaging preparation.
G: Position the client side-lying with their knees to their chest. This positioning is unrelated to MRI procedures and does not address any specific requirements for the examination.
The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad?
Rationale:
Irregular respirations, bradycardia, and widening pulse pressure support a diagnosis of Cushing's triad. This triad indicates increased intracranial pressure, where irregular breathing patterns, slowed heart rate, and widened pulse pressure are classic clinical manifestations signaling a critical brain injury or hemorrhage.
A: Hypotension, jugular venous distention, and muffled heart tones. These signs suggest cardiac tamponade or severe hypovolemia rather than the specific neurological implications of Cushing's triad.
C: Fixed pupils, hypotension, and bradycardia. While some symptoms overlap, fixed pupils indicate severe neurological compromise, diverging from the respiratory patterns characteristic of Cushing's triad.
D: Bradycardia, hypotension, and bradypnea. Although bradycardia and hypotension are present, bradypnea lacks the irregularity seen in Cushing's triad, which is crucial for proper diagnosis.
The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
Rationale:
The rehabilitation plan should be implemented early in the client's treatment. Early rehabilitation is crucial for maximizing recovery potential, promoting independence, and ensuring the client learns essential self-care skills to manage their condition effectively.
A: The client and their family members will arrange for rehabilitation. While family involvement is important, they should not solely handle rehabilitation arrangements, which require professional guidance and support.
C: The client should plan for minimal and short-term rehabilitation, as they will return to their former activities. Paraplegic clients typically require extensive rehabilitation, not minimal, to adjust to their new circumstances.
D: Long-term care should be arranged, as the client can no longer perform self-care. Although long-term care may be needed, emphasizing self-care skills and rehabilitation is essential for improving the client’s independence.
The nurse is performing an assessment on a client with Wernicke's aphasia. Which client finding would be consistent with this diagnosis?
Rationale:
D: Speaks with normal fluency and prosody. Wernicke's aphasia is characterized by fluent speech that lacks meaningful content. Individuals often produce grammatically correct sentences but struggle with understanding and contextual relevance.
A: Loss of ability to execute or carry out skilled movements. This describes apraxia, not Wernicke's aphasia, as it pertains to motor skills rather than language comprehension or production.
B: Cannot express any words. This situation aligns more closely with Broca's aphasia, where individuals have significant difficulty forming words and sentences, contrasting with the fluent speech seen in Wernicke's aphasia.
C: Cannot swallow liquids. Difficulty swallowing, or dysphagia, relates to physical function and does not specifically indicate Wernicke's aphasia, which is primarily a language processing disorder.
The RN is caring for a client who is recovering from carotid endarterectomy. Which assessment would the nurse recognize as a sign that the client experienced hypoglossal nerve injury?
Rationale:
Tongue deviation.
Tongue deviation indicates potential hypoglossal nerve injury, as this nerve controls tongue movement. A client exhibiting this sign may have compromised muscle control, leading to asymmetrical positioning of the tongue, which is a critical assessment post-cervical surgical procedures.
B: Inspiratory stridor. This symptom is associated with airway obstruction or laryngeal issues, not specifically linked to hypoglossal nerve function, making it unrelated to the assessment of nerve injury.
C: Tracheal deviation. Tracheal deviation suggests structural or positional changes within the thoracic cavity, which do not directly relate to the function of the hypoglossal nerve or tongue movement assessment.
D: Severe headache. While headaches can indicate various complications post-surgery, they do not provide specific insight into hypoglossal nerve impairment or tongue functionality, lacking direct relevance in this context.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a 15-year-old who has sustained a sports-related injury
Item 1 of 1
Triage Note Triage Vital Signs
1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
The nurse assigned to the client reviews the triage note and plans care
The nurse anticipates taking which action? Prepare the client for a computed tomography (CT) scan of the head
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Prepare the client for a computed tomography (CT) scan of the head
B
Perform a Glasgow Coma Scale (GCS)
C
Encourage by mouth (PO) fluids
D
Assess the client's pupils
E
Prepare the client for a lumbar puncture (LP)
Rationale:
Prepare the client for a computed tomography (CT) scan of the head. This action is crucial due to the patient's head injury, loss of consciousness, and reported symptoms, indicating a potential intracranial injury that requires imaging for proper diagnosis and treatment.
B: Perform a Glasgow Coma Scale (GCS) Assessment of the client's consciousness level is important, but the priority is obtaining imaging to rule out serious complications given the loss of consciousness.
C: Encourage by mouth (PO) fluids Hydration is beneficial; however, with a potential head injury, the risk of complications makes immediate imaging more critical than fluid intake at this stage.
D: Assess the client's pupils While pupil assessment is essential to evaluate neurological status, preparing for a CT scan takes precedence in cases of suspected intracranial injury.
E: Prepare the client for a lumbar puncture (LP) A lumbar puncture is inappropriate at this moment, as it poses risks when intracranial pressure may be elevated due to a head injury.
The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus?
Rationale:
Rapid, rhythmic muscle contractions indicate a positive result for clonus. This finding suggests hyperactivity in the neuromuscular system, often associated with neurological conditions, where involuntary muscle contractions occur in a repetitive manner during assessment.
A: Rubor of the feet and ankles when the leg is in the dependent position reflects vascular changes, not muscle activity, and does not indicate clonus or its presence.
C: Popping or clicking of the knee joint with movement signifies joint instability or cartilage issues, unrelated to the involuntary muscle contractions that characterize clonus.
D: Audible cracking and palpable grating with movement of the joints point to potential osteoarthritis or joint degeneration, rather than the rhythmic muscle contractions indicative of clonus.
The nurse is caring for a client scheduled for a lumbar puncture (LP). Which of the following clinical manifestations would require follow-up by the nurse before the LP?
Rationale:
Nuchal rigidity, temperature of 101° F, and a petechial rash require follow-up by the nurse before the lumbar puncture. These signs may indicate serious underlying conditions such as meningitis or a bleeding disorder, necessitating a thorough assessment to ensure the client's safety prior to the procedure and to prevent potential complications during the LP.
B: Temperature 101° F (38.3° C) Elevated temperature can signal infection or inflammation, which may complicate the lumbar puncture procedure, increasing the risk of adverse effects during and post-procedure.
C: Petechial rash Indicates potential bleeding disorders or infections like meningococcal disease, which require immediate evaluation. This manifestation could lead to severe complications if not addressed prior to the lumbar puncture.
D: Restlessness While restlessness may indicate anxiety or discomfort, it is less critical than the other symptoms. It does not directly suggest a medical condition that would necessitate postponing the lumbar puncture.
The nurse cares for a client who sustained a stroke impacting the occipital lobe. Which of the following assessment findings would support this diagnosis?
Rationale:
Homonymous hemianopia is the assessment finding that supports the diagnosis of a stroke impacting the occipital lobe. This condition results from damage to the visual pathways in the occipital lobe, affecting visual perception in one half of the visual field, which aligns with the expected consequences of such a stroke.
B: Impaired proprioception This symptom typically relates to issues in the parietal lobe, which processes sensory information regarding body position, not the occipital lobe's visual function.
C: Expressive aphasia This condition arises from damage to Broca's area in the frontal lobe, affecting speech production, rather than being a consequence of occipital lobe impairment linked to vision.
D: Impulsivity This behavior is commonly associated with frontal lobe injuries, where decision-making and self-control are managed, rather than being indicative of dysfunction in the occipital lobe.
The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client's plan of care?
Rationale:
Observe the client during meals. This is essential as impairment to the hypoglossal cranial nerve can affect tongue movement, leading to swallowing difficulties and increasing the risk of aspiration during eating.
B: Keep suction at the bedside. While this may be useful for other conditions, it does not directly address the specific challenges posed by hypoglossal nerve impairment during meals.
C: Provide large print education materials. Visual impairment is unrelated to hypoglossal nerve function; this option does not cater to the specific issues of swallowing or tongue control.
D: Teach the client to scan the room. Scanning is related to visual field awareness, which does not correlate with the motor functions affected by hypoglossal nerve impairment.
E: Alternate the use of an eye patch. This option pertains to eye conditions and does not address the motor impairments associated with the hypoglossal cranial nerve's impact on speech and swallowing.
After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the:
Rationale:
Loss of motor function would be assessed in the legs. A complete spinal cord injury at L3 affects the nerves that control leg movement, leading to potential paralysis below that level.
A: Abdomen The abdominal muscles are primarily controlled by nerves from higher spinal levels, thus sparing them from direct impact due to an L3 injury.
B: Arms Nerves controlling arm movement originate from cervical levels, making them unaffected by a spinal cord injury at the L3 level.
D: Chest The chest's motor functions are predominantly linked to thoracic nerves, which remain intact despite a complete injury at the L3 spinal cord level.
The nurse is teaching a client with Parkinson's disease about dietary considerations. The nurse understands that this client is at highest risk for
Rationale:
Dysphagia and aspiration. Individuals with Parkinson's disease often experience difficulty swallowing, known as dysphagia, which increases the risk of aspiration, leading to serious respiratory complications and impaired nutrition.
A: Constipation and drooling. While constipation is common in Parkinson's patients, drooling is less serious than dysphagia and aspiration, which pose more immediate health risks related to swallowing difficulties.
B: Drooling and a loss of appetite. Although drooling can occur, it does not represent the highest risk. Loss of appetite is a symptom but does not directly lead to life-threatening conditions like aspiration.
C: Loose stools and choking. Loose stools are not commonly associated with Parkinson's disease, and choking primarily relates to dysphagia, making this option less relevant to the critical dietary concerns of the condition.
In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia?
Rationale:
Sudden headache, flushed face, nasal congestion, and profuse sweating above the level of the injury are indicative symptoms of autonomic dysreflexia in clients with spinal cord injury. This condition arises due to an overactive autonomic response to stimuli below the injury level, leading to these characteristic symptoms.
A: Hypotension This symptom contradicts the typical presentation of autonomic dysreflexia, which usually causes hypertension due to excessive sympathetic nervous system activity instead of lowering blood pressure.
E: Profuse sweating above the level of the injury While sweating occurs, this is not a primary or defining symptom of autonomic dysreflexia; it can be associated with other conditions as well.
The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain?
Rationale:
Respiratory rate. In clients with cervical spinal cord injuries, respiratory function is often compromised due to potential diaphragm paralysis, making respiratory rate a critical vital sign to monitor for adequate ventilation and oxygenation.
B: Blood Pressure. While important, blood pressure changes can occur later in cervical injuries; respiratory complications typically arise more immediately, necessitating a focus on respiratory rate first.
C: Pulse. Although pulse can indicate cardiac function, it does not directly reflect respiratory adequacy, which is vital in patients with compromised spinal cord integrity and potential respiratory failure.
D: Temperature. Monitoring temperature is essential for assessing infection or homeostasis, but it does not provide immediate information about respiratory status, making it less critical in this scenario.
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 3 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.
The client is at highest risk for developing …………………..
Rationale:
The client is at highest risk for developing bacterial meningitis. The symptoms of neck stiffness, fever, and altered mental status, coupled with recent influenza-like illness, suggest a potential central nervous system infection, particularly meningitis.
B: Influenza The client’s roommate reported recent influenza but the client’s symptoms, particularly neurological signs, indicate a more severe condition rather than viral illness alone.
C: Benzodiazepine toxicity The use of non-prescribed lorazepam could contribute to sedation, but the presence of fever and neck stiffness points more towards an infectious process than simple drug effects.
A client is admitted with a possible diagnosis of Guillain-Barré syndrome. Which important question should the nurse include when taking this client's history?
Rationale:
Did you have a recent respiratory or gastrointestinal infection?
Recent infections, particularly of the respiratory or gastrointestinal tract, are often associated with Guillain-Barré syndrome, as they can trigger the immune response leading to this condition. Gathering this information helps the nurse assess the potential cause of the client's symptoms and guide further investigation and treatment.
A: Do you experience frequent bruising? Frequent bruising typically indicates clotting disorders, which are not directly linked to Guillain-Barré syndrome. This inquiry would not provide relevant information for the diagnosis.
C: Have you been overseas during the past four months? While travel can expose individuals to various infections, this question does not specifically address the known triggers or associations related to Guillain-Barré syndrome.
D: Has anybody in your family had Guillain-Barré syndrome? Family history may provide insight into genetic predispositions, yet it does not account for the environmental factors or recent infections that frequently precede the syndrome's onset.
The nurse is preparing to teach a client who was recently diagnosed with Meniere's disease. To help the client reduce the incidence of attacks, the nurse should recommend that the client do which of the following?
Rationale:
Reduce dietary sodium intake. This recommendation is essential for clients with Meniere's disease, as high sodium levels can lead to fluid retention, worsening inner ear symptoms and increasing the likelihood of attacks.
A: Irrigate their ears with sterile water. This action does not address the underlying issue of fluid balance or dietary factors that contribute to Meniere's disease management.
C: Do not use earbuds or headphones. While this may prevent discomfort, it does not influence the physiological causes of Meniere's disease or reduce attack frequency effectively.
D: Speak with limited inflections. Limiting vocal inflection does not directly correlate with managing the symptoms or triggers associated with Meniere's disease and its attacks.
The nurse is assessing a client with suspected autonomic dysreflexia. Which assessment findings would support the diagnosis of autonomic dysreflexia?
Rationale:
Severe headache, piloerection, and restlessness support the diagnosis of autonomic dysreflexia. These symptoms indicate a significant autonomic response, often triggered by noxious stimuli below the level of injury, leading to hypertension and other symptoms.
B: Piloerection does not solely indicate autonomic dysreflexia; it can be associated with other conditions as well. Alone, it lacks the specificity required for this diagnosis.
C: Hypotension contradicts the typical presentation of autonomic dysreflexia, where increased blood pressure is a hallmark symptom. Therefore, it does not align with the expected findings.
D: Tachycardia may occur in various conditions and does not specifically indicate autonomic dysreflexia. Other factors could lead to an increased heart rate without confirming this diagnosis.
E: Restlessness can be caused by multiple factors unrelated to autonomic dysreflexia, such as anxiety or pain. It does not distinctly support the diagnosis on its own.
The nurse is planning a staff education program about seizures. It would be correct for the nurse to characterize complex partial seizures as
Rationale:
Individuals experiencing complex partial seizures maintain a degree of awareness, although they may have impaired consciousness. This distinguishes them from other seizure types, highlighting the unique characteristics of their conscious experience during episodes.
A: A seizure that may cause syncope lasting for 1 to 3 minutes. This description pertains more to generalized seizures and does not accurately reflect the consciousness level in complex partial seizures.
C: A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion. This relates to atonic seizures rather than complex partial seizures, which do not typically involve sudden muscle tone loss.
D: A brief jerking or stiffening of the extremities that may occur singly or in groups. This describes myoclonic seizures, which differ significantly from complex partial seizures in terms of consciousness and presentation.
The nurse is caring for an elderly home health client experiencing a sudden onset of delirium. Which of the following should the home health nurse assess first?
Rationale:
A: Drug intoxication
Assessing for drug intoxication is paramount as it can rapidly alter mental status, particularly in elderly clients. Identifying potential substance abuse or medication side effects is crucial for appropriate management and intervention.
B: Increased hearing loss
While hearing loss can affect communication, it does not typically cause sudden delirium. Assessing hearing issues does not address the immediate changes in mental status that the client is experiencing.
C: Cancer metastases
Cancer metastases may contribute to delirium over time, but they are not an immediate cause. This assessment would be less urgent than evaluating potential drug-related changes in the client's condition.
D: Congestive heart failure
Congestive heart failure can lead to various symptoms, but it is less likely to cause acute delirium. Immediate evaluation of drug intoxication takes precedence over assessing chronic health conditions in this scenario.
The following scenario applies to the next 1 items
The intensive care unit nurse has completed the assessment of a client
Item 1 of 1
Nurses' Notes
Progress Notes Orders
Day 2
1445: Physician at the bedside. The client is sedated, receiving mechanical ventilation via the #8 endotracheal tube. Current ventilator settings: assist control; rate 12/minute; tidal volume 450 mL; FiO 2 100%; positive end-expiratory pressure (PEEP) 5 cm H20. Intraventricular catheter present and zeroed and calibrated. No purposeful movement, and pupils were 3 mm equally round and sluggish to light. No abnormal posturing. + gag reflex; + corneal reflex. Lung sounds clear bilaterally, and the chest rises and falls synchronously with the ventilator. Peripheral pulses 2+ and S1 and S2 heart tones. Normoactive bowel sounds in all quadrants, no abdominal distention. Skin warm and dry. Indwelling urinary catheter patent and draining clear, concentrated urine. The client is currently positioned in a semi-Fowler position.
The nurse reviews the physician's orders
Click to specify if the order is indicated or requires follow-up with the physician:
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
0.45% saline infusion
B
increase PEEP to 15 cm H20
C
enoxaparin subcutaneously
D
levetiracetam intravenous piggy-back
E
pneumatic compression devices to the lower extremities
F
repeated computed tomography (CT) scan
Rationale:
Increase PEEP to 15 cm H20.
Elevating the PEEP to 15 cm H20 is warranted in this scenario, as the client is on mechanical ventilation with 100% FiO2 and shows no improvement in oxygenation, suggesting potential recruitment of collapsed alveoli to enhance ventilation-perfusion matching.
A: 0.45% saline infusion poses a risk of fluid overload in a sedated, mechanically ventilated client, particularly when clear, concentrated urine output indicates potential renal concerns.
C: Enoxaparin subcutaneously is not indicated at this time, as there is no evidence of thromboembolic events that would necessitate anticoagulation for the client’s current condition.
D: Levetiracetam intravenous piggy-back is unnecessary since there are no documented seizures or indications of seizure activity in the client's assessment, making this order irrelevant.
E: Pneumatic compression devices to the lower extremities are not currently indicated because the client is stable and does not exhibit signs of venous thromboembolism or poor circulation requiring prophylaxis.
F: A repeated computed tomography (CT) scan is not warranted at this moment, as the client’s status does not suggest any new or worsening conditions that necessitate further imaging.
The following scenario applies to the next 1 items
The nurse cares for a 75-year-old client who arrives at the emergency department
Item 1 of 1
History And Physical
Vital Signs
1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress: Condition
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Transport the client for computed tomography (CT) scan
B
Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
C
Complex Migraine
D
Severe Hypoglycemia
E
Cerebral Vascular Accident
F
Vital Signs
G
Glasgow Coma Scale (GCS)
Rationale:
E: Cerebral Vascular Accident
The client is likely experiencing a Cerebral Vascular Accident (CVA), evidenced by sudden left facial droop, inability to move her left arm and leg, and expressive aphasia, indicating a stroke.
A: Transport the client for computed tomography (CT) scan
Immediate imaging is necessary to determine the type and extent of the stroke, guiding subsequent treatment decisions effectively.
B: Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
While useful for broader assessment, laboratory tests do not provide immediate information needed for acute stroke management compared to imaging.
C: Complex Migraine
Symptoms described do not align with a complex migraine, which typically includes headache as a primary feature rather than acute neurological deficits like facial droop and weakness.
D: Severe Hypoglycemia
Severe hypoglycemia can cause confusion and weakness, but the specific sudden onset of neurological symptoms strongly suggests a stroke rather than low blood sugar.
F: Vital Signs
Monitoring vital signs is essential in a general sense but does not directly address the specific neurological crisis presented by the client's condition.
G: Glasgow Coma Scale (GCS)
While GCS is a valuable assessment tool, it does not provide the immediate diagnostic clarity needed to evaluate the suspected stroke in this scenario.
The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
Rationale:
Elevating the head of the bed is the first action the nurse should perform. This position helps decrease blood pressure and alleviate the symptoms of autonomic dysreflexia by promoting venous return and reducing intracranial pressure.
A: Administer sublingual nitroglycerin. While nitroglycerin can help lower blood pressure, it is not the immediate priority in managing autonomic dysreflexia, which requires rapid positional adjustments first.
C: Obtain a residual volume reading with a bladder scan. Assessing bladder volume is important, but immediate intervention focuses on alleviating the acute symptoms of autonomic dysreflexia rather than diagnostic measures.
D: Perform a digital examination to assess for the presence of stool. Checking for stool is relevant but should follow initial actions that directly address the critical symptoms of autonomic dysreflexia.
A nurse is caring for a client on bed rest following a spinal cord injury. When positioning the client's feet, which position would prevent the client from developing foot drop?
Rationale:
B: Dorsiflexion. Positioning the feet in dorsiflexion maintains the ankle in a neutral position, preventing the toes from pointing downward, which is crucial for avoiding foot drop in immobilized clients.
A: Supination. This position refers to turning the palm or foot upwards, which does not address the specific concern of maintaining the ankle’s proper alignment to avoid foot drop.
C: Hyperextension. Hyperextension involves extending a joint beyond its normal limits, potentially leading to instability and increased risk of complications rather than promoting the correct foot positioning to prevent foot drop.
D: Abduction. This indicates moving a limb away from the midline of the body, which does not support the necessary alignment of the foot and ankle to prevent foot drop effectively.
The nurse has administered the first dose of prescribed rivastigmine to a client with Alzheimer's disease. Which clinical data is necessary to monitor while this client takes this medication?
Rationale:
Monitoring weight is essential for clients taking rivastigmine, as this medication can lead to gastrointestinal side effects that may impact appetite and result in weight loss. Regular assessment helps manage these potential complications and ensure the client’s overall well-being.
A: Glucose Monitoring glucose levels is not directly related to rivastigmine use, as this medication primarily affects cognitive function rather than metabolic processes associated with blood sugar regulation.
C: Creatinine While renal function is important in medication management, rivastigmine does not primarily impact kidney function, making creatinine levels less relevant for monitoring in this context.
D: Hemoglobin and hematocrit Monitoring hemoglobin and hematocrit is unnecessary for rivastigmine therapy, as this medication does not directly influence blood cell production or lead to significant changes in these parameters.
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
Rationale:
Decreased muscle spasms. Tizanidine is primarily prescribed as a muscle relaxant, effectively reducing muscle spasticity and discomfort. A client's report of decreased muscle spasms indicates that the medication is achieving its intended therapeutic effect.
A: Increased ability to focus. Tizanidine does not enhance cognitive functions such as focus; its main purpose is to alleviate muscle tightness and spasms.
C: Improved short-term memory. This medication does not target memory improvement; its action is centered on muscle relaxation rather than cognitive enhancement or memory support.
D: Sleeping without awakening at night. While tizanidine may cause sedation, it is not designed to specifically improve sleep quality or duration, making this response inaccurate.
The nurse is reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
Rationale:
The client's phenytoin level is 12 mcg/mL, which falls within the therapeutic range of 10-20 mcg/mL, indicating that the medication is being effectively administered.
D: Document the result as within normal limits. This action is appropriate since the phenytoin level is within the therapeutic range, suggesting effective medication management and no immediate concerns for adjustment or intervention.
A: Evaluate the client for non-adherence. This step is unnecessary as the phenytoin level indicates effective treatment, not non-adherence, so further evaluation of compliance is unwarranted.
B: Instruct the client to skip the next scheduled dose. Skipping a dose would be inappropriate since the current level is therapeutic, and doing so could disrupt effective management of the client’s condition.
C: Assess the client for phenytoin toxicity. With a level of 12 mcg/mL, there are no signs of toxicity; therefore, assessing for toxicity is not warranted at this therapeutic range.
The nurse is assessing a client receiving prescribed donepezil. Throughout the duration of therapy, the nurse should monitor the client's
Rationale:
The client’s pulse should be monitored throughout therapy. Donepezil can cause bradycardia, leading to a decreased heart rate, which necessitates regular assessment to ensure the patient's cardiovascular stability and safety.
B: Fasting blood glucose Monitoring fasting blood glucose is not directly relevant to donepezil therapy, as this medication primarily targets cognitive function rather than impacting glucose metabolism or levels significantly.
C: Total cholesterol Total cholesterol levels are not a primary concern with donepezil use, as the drug's effects focus on cognitive enhancement in Alzheimer’s disease rather than lipid profiles or cardiovascular risk.
D: Pulse oximetry Regular pulse oximetry is unnecessary in this context, as donepezil does not directly affect oxygen saturation levels, making it an irrelevant monitoring parameter for clients receiving this medication.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. The nurse anticipates that the physician will prescribe which medications? Select all that apply.
Rationale:
Prednisone, Valacyclovir. The physician is likely to prescribe these medications as they are commonly used to reduce inflammation and manage viral infections associated with Bell's palsy exacerbations, facilitating recovery.
B: Donepezil A medication primarily used for Alzheimer's disease, it does not address the inflammatory or viral components related to Bell's palsy.
C: Pyridostigmine This drug treats myasthenia gravis, not applicable for Bell's palsy, which involves facial nerve inflammation rather than neuromuscular junction issues.
E: Topiramate An anticonvulsant used for seizures and migraines, it does not target the underlying causes of Bell's palsy, making it unsuitable for this condition.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
Rationale:
Sumatriptan is intended to treat migraine headache. This medication works by narrowing blood vessels in the brain and relieving the symptoms associated with migraines, providing significant relief to affected clients.
A: Peripheral artery disease. Sumatriptan does not address circulatory issues or vascular complications related to peripheral artery disease, which requires different therapeutic approaches to improve blood flow.
B: Accelerated hypertension. This condition involves severely elevated blood pressure and is managed with antihypertensive medications, not sumatriptan, which is specifically indicated for migraine treatment.
D: Angina. Angina pertains to chest pain due to reduced blood flow to the heart, necessitating cardiac-related treatments rather than the migraine-specific action of sumatriptan.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
Rationale:
B: I will need laboratory work to monitor the medication level. Regular monitoring of phenytoin levels is crucial to ensure therapeutic effectiveness and prevent toxicity, highlighting the client’s understanding of necessary medical oversight.
A: If my gums get irritated and large, I can stop this medication. Stopping phenytoin suddenly can lead to seizures; instead, the client should consult a healthcare provider for advice.
C: It is okay for me to increase this medication if I have a seizure. Self-adjusting medication dosage can result in dangerous side effects or ineffective treatment; medical guidance is essential.
D: I should take this medication with low protein foods. Phenytoin absorption can be affected by protein intake; thus, there is no specific recommendation to pair it with low protein foods.
The nurse has administered the first dose of prescribed rivastigmine to a client with Alzheimer's disease. Which clinical data is necessary to monitor while this client takes this medication?
Rationale:
Weight monitoring is necessary for clients taking rivastigmine as this medication can cause gastrointestinal side effects, potentially leading to weight loss. Regular assessment helps ensure nutritional status and overall health are maintained during treatment.
A: Glucose Monitoring glucose levels is not a primary concern with rivastigmine, as this medication primarily affects cognitive function rather than blood sugar regulation, making it less relevant.
C: Creatinine While assessing kidney function is essential, rivastigmine does not directly impact renal parameters, making creatinine levels less critical for monitoring in this context.
D: Hemoglobin and hematocrit Monitoring hemoglobin and hematocrit levels is not specifically necessary for rivastigmine, as the medication does not significantly affect blood cell production or cause anemia in most cases.
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
Rationale:
Decreased muscle spasms. Tizanidine is primarily prescribed for its muscle relaxant properties, targeting spasticity and reducing muscle tension, which directly aligns with the client's report of decreased muscle spasms as a therapeutic effect.
A: Increased ability to focus. Tizanidine does not directly enhance cognitive functions or concentration, so reporting improved focus does not indicate the intended effect of the medication.
C: Improved short-term memory. This medication is not indicated for cognitive enhancement or memory improvement, making a report of better short-term memory unrelated to its therapeutic action.
D: Sleeping without awakening at night. Tizanidine may cause sedation, but it is not specifically aimed at addressing sleep disturbances or ensuring uninterrupted sleep, making this report unrelated to its main effects.
The nurse is reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
Rationale:
The client’s phenytoin level is 12 mcg/mL, which falls within the therapeutic range of 10-20 mcg/mL. Therefore, it is appropriate for the nurse to document this result as normal.
A: Evaluate the client for non-adherence. The phenytoin level indicates adherence to the medication regimen, negating the need for evaluation of non-adherence at this point.
B: Instruct the client to skip the next scheduled dose. Since the phenytoin level is within the therapeutic range, skipping a dose could disrupt effective treatment and is unnecessary.
C: Assess the client for phenytoin toxicity. With a level of 12 mcg/mL being within the acceptable range, there are no signs of toxicity to warrant an assessment for such.
The nurse is assessing a client receiving prescribed donepezil. Throughout the duration of therapy, the nurse should monitor the client's
Rationale:
The client’s pulse should be monitored throughout donepezil therapy due to the potential for bradycardia as a side effect of the medication. This is crucial for detecting any significant changes in heart rate that could indicate complications.
B: Fasting blood glucose Measuring fasting blood glucose is not directly relevant to donepezil therapy, as the medication primarily affects cognitive function rather than glycemic control or diabetes management.
C: Total cholesterol Donepezil does not have a direct correlation with cholesterol levels, making total cholesterol monitoring unnecessary in the context of evaluating the drug's efficacy or side effects.
D: Pulse oximetry Monitoring pulse oximetry is not pertinent to donepezil therapy, as it primarily assesses oxygen saturation and respiratory function, which are not directly influenced by this medication.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. The nurse anticipates that the physician will prescribe which medications? Select all that apply.
Rationale:
Prednisone and Valacyclovir are the anticipated medications for a client with an acute exacerbation of Bell's palsy. Prednisone reduces inflammation, while Valacyclovir addresses potential viral causes, aiding recovery.
B: Donepezil This medication is primarily used for Alzheimer's disease and does not address the underlying inflammation or viral component associated with Bell's palsy.
C: Pyridostigmine This drug is designed for myasthenia gravis treatment and does not provide the necessary therapeutic effects for managing Bell's palsy symptoms.
E: Topiramate Primarily used as an anticonvulsant, this medication does not target the inflammatory or viral aspects present in Bell's palsy exacerbations.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
Rationale:
Sumatriptan is intended to treat migraine headaches. This medication works by constricting blood vessels in the brain and alleviating migraine symptoms, providing relief from the debilitating effects associated with these episodes.
A: Peripheral artery disease does not relate to sumatriptan, which specifically targets migraine headaches rather than circulatory issues affecting the arteries in the limbs.
B: Accelerated hypertension is not treated with sumatriptan; the medication is focused on managing migraine symptoms rather than addressing blood pressure elevation or related cardiovascular conditions.
D: Angina is unrelated to the purpose of sumatriptan, which is designed for migraine relief rather than for treating chest pain associated with heart conditions.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
Rationale:
B: I will need laboratory work to monitor the medication level. This statement reflects the necessity of regular monitoring of phenytoin levels to prevent toxicity and ensure effective therapeutic outcomes, highlighting the importance of adherence to medical guidelines.
A: If my gums get irritated and large, I can stop this medication. Discontinuing phenytoin without consulting a healthcare provider can lead to increased seizure risk and potential complications.
C: It is okay for me to increase this medication if I have a seizure. Self-adjusting medication dosages can be dangerous and should always involve healthcare provider consultation for safety and efficacy.
D: I should take this medication with low protein foods. Phenytoin absorption can be affected by food, but low protein diets may not provide the necessary balance for optimal medication efficacy.
The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?
Rationale:
Difficulty swallowing liquids requires follow-up. This symptom may indicate complications such as nerve damage or swelling affecting the client's ability to safely ingest food and fluids post-surgery.
A: Active range of motion in both arms Assessing range of motion is essential for recovery; this evaluation helps determine if the client's strength and function are improving without indicating a complication.
B: Scant drainage on the dressing Minimal drainage can be expected and may signify normal healing. It's important to monitor for excessive drainage, which would indicate a potential issue.
D: Soreness at the operative site Mild soreness is a typical postoperative finding and often signals the body's natural healing process. It doesn't inherently suggest complications requiring immediate intervention.
The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity?
Rationale:
Circadian rhythm. This term refers to the natural, internal process that regulates the sleep-wake cycle and other physiological processes, following an approximately 24-hour cycle influenced by light and darkness.
A: REM sleep. This term specifically pertains to a stage of sleep characterized by rapid eye movement, rather than describing the overall daily cycle of wakefulness and activity.
C: Diurnal rhythm. While closely related to daily patterns, this term does not encompass the broader internal timing mechanisms that govern various body functions over a 24-hour period.
D: Nocturnal activity. This phrase refers to behaviors occurring during the night, lacking the comprehensive scope of biological processes that a circadian rhythm encompasses across both day and night.
The following scenario applies to the next 1 items
The emergency department nurse is caring for a 27-year-old male client.
Item 1 of 1
Nurses' Notes
1500: Client reports an 'excruciating' headache right behind his left eye. He says the pain is 'pulsating' and worse when lying down. He reports sensitivity to lights and sounds. He reports getting these headaches daily for the past two weeks at about the same time. He states that the headache lasts one to two hours. On assessment, the client appears in moderate distress; he is alert, oriented, and has tearing in his left eye. His gait was steady as he paced around the exam room because having him sit down to obtain vital signs increased his pain. Lung sounds are clear; peripheral pulses were 2+. Normoactive bowel sounds. He reports his pain rated 9/10 on the Numerical Rating Scale.
The client is demonstrating clinical manifestations consistent with
Rationale:
The client is demonstrating clinical manifestations consistent with cluster headache. The symptoms, including an excruciating, pulsating headache behind the left eye, sensitivity to light and sound, and tearing, align with cluster headaches, which typically cause severe unilateral pain that occurs in cyclical patterns.
B: Tension headache. The nature of the headache as pulsating and excruciating, along with the specific location, diverges from the more generalized pain associated with tension headaches.
C: Trigeminal neuralgia. The acute, severe pain reported by the client is not characteristic of trigeminal neuralgia, which typically involves brief, sharp facial pain rather than a prolonged headache.
D: Migraine headache. Although migraines can cause severe headaches, the specific patterns and symptoms, such as the tearing and precise location, more accurately indicate a cluster headache rather than a migraine.
The following scenario applies to the next 1 items
The outpatient clinic nurse cares for a 40-year-old female client.
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Nurses' Notes
1450: Client reports to the clinic with her daughter because of various concerning symptoms that started about eight months ago. The client's daughter has noticed that her mother has become increasingly clumsy and uncoordinated. She reports that she is tripping over her own feet, which has caused her to fall twice. The client's daughter also reports becoming emotionally labile for 'no apparent reason.' The client reports that she gets 'spells of double vision that lasts for a few days' that seem to worsen with the heat. The client's daughter is concerned because her mother is not the 'get up and go' type of woman she used to be. The client does endorse generalized fatigue that worsens as the day progresses. In fact, she states
She goes to bed early because she gets so tired by 6 pm. The client says that two weeks ago, her vision doubled so much that she purchased an eye patch at the drugstore, which did help. Her daughter reports checking on her mother; her language was garbled and unrecognizable. She was almost ready to take her to the ED because she thought she was having a stroke. Finally, the client provided documentation from two urgent care visits in the past six months because of urinary tract infections. The client indicates she has had urinary problems dealing with urgency. She states that she has no pain, and in fact, she has difficulty determining if she has a UTI because she has decreased sensation in her pelvic region, which she cannot explain. On assessment, the client's breathing is unlabored, and breath sounds are clear bilaterally. Skin warm to touch with no tenting; bruising noted on the client's shins; pulses 2+ and regular. Capillary refill is 3 seconds. The client is alert and oriented to person, place, and situation. She currently takes no medications and has a medical history of uterine fibroids.
For each client finding below, click to specify if the finding is consistent with the disease process of Parkinson's disease, myasthenia gravis, or multiple sclerosis:
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Diplopia
B
Emotional lability
C
generalized fatigue
D
Muscle incoordination
E
diminished response to pain
F
heat sensitivity
G
urinary urgency
Rationale:
Emotional lability is consistent with the disease process of multiple sclerosis. This symptom reflects the neurological impacts of multiple sclerosis, where emotional dysregulation is common due to lesions affecting mood-related brain areas.
A: Diplopia Double vision is typically associated with multiple sclerosis due to its impact on ocular muscles and neurological control rather than myasthenia gravis or Parkinson's disease.
C: Generalized fatigue Fatigue is a common symptom in multiple sclerosis but may also appear in other conditions, making it less definitive for this specific diagnosis.
D: Muscle incoordination Although muscle incoordination aligns with both multiple sclerosis and Parkinson's disease, it does not specifically point to the unique characteristics of emotional lability.
E: Diminished response to pain This symptom is not a hallmark of multiple sclerosis but can be more indicative of other neurological disorders.
F: Heat sensitivity Sensitivity to heat is primarily associated with multiple sclerosis exacerbating symptoms, not directly related to emotional lability.
G: Urinary urgency Urinary urgency can be seen in multiple sclerosis but is not directly linked to emotional lability itself.
Minutes after administering an intravenous dose of 10 mg of morphine, the nurse notes that the client's blood pressure has dropped from 122/83 mmHg to 88/67 mmHg, and the client's respirations are now 8/minute. Which nursing action is the most appropriate?
Rationale:
Administer naloxone. This option rapidly reverses opioid-induced respiratory depression and hypotension, addressing the critical symptoms of low respiratory rate and significant blood pressure drop after morphine administration, ensuring patient safety.
A: Prepare for intubation. This action may be necessary in severe cases but is not the immediate priority when naloxone can effectively restore respiratory function and blood pressure.
B: Prepare to administer a dopamine infusion. While dopamine can support blood pressure, it does not address the underlying cause of respiratory depression caused by morphine and may delay appropriate treatment.
D: Start an intravenous infusion of normal saline. Administering fluids may help with blood pressure, but it does not resolve the critical respiratory depression that requires urgent intervention with naloxone.
The nurse is preparing a staff in-service regarding conductive hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
Rationale:
Conductive hearing loss can be caused by the presence of a foreign body in the ear canal and excessive cerumen buildup, both of which obstruct sound transmission to the inner ear.
A: Presbycusis Age-related hearing loss primarily affects the inner ear, not sound conduction, thus it does not contribute to conductive hearing loss, which involves blockages or disruptions along the auditory pathway.
B: Prolonged exposure to noise This primarily results in sensorineural hearing loss rather than conductive hearing loss, as it damages the inner ear structures responsible for sound processing.
D: Ototoxic substance While ototoxic substances can harm hearing, they typically lead to sensorineural hearing loss by affecting the inner ear, rather than causing any conductive issues in sound transmission.
The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by:
Rationale:
Delirium can be caused by fever, hypoglycemia, and infection. These factors disrupt normal brain function, leading to acute confusion and altered mental states, making them significant contributors to delirium onset.
B: Alzheimer's disease Although it affects cognition, Alzheimer's is a progressive condition rather than an acute cause of delirium, which typically emerges suddenly due to various other medical factors.
D: Vascular disease While vascular conditions can impact brain health, they generally contribute to chronic cognitive decline rather than the immediate onset of delirium, which requires acute triggers.
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
Rationale:
Unilateral frontotemporal pain indicates a typical presentation of migraine headaches. This pain is often localized to one side of the head, highlighting the specific nature of migraine-related discomfort experienced by the client.
D: Fever A fever does not typically accompany migraines and is more indicative of an infection or other medical issue, rather than a primary headache disorder.
E: Nuchal rigidity Nuchal rigidity suggests potential meningeal irritation or infection, which is unrelated to the typical symptoms of a migraine headache.
The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?
Rationale:
Atonic seizure. This type of seizure is characterized by a sudden loss of muscle tone, leading to a brief period of weakness or collapse, often lasting just a few seconds.
B: Tonic-clonic seizure. This seizure involves both tonic (stiffening) and clonic (jerking) phases, which are not consistent with the described sudden loss of muscle tone.
C: Absence seizure. These seizures manifest as brief lapses in awareness or consciousness, not a sudden loss of muscle tone, and do not involve physical collapse.
D: Complex partial seizure. This type involves altered consciousness and may include unusual movements, but it does not specifically cause the sudden loss of muscle tone as described.
The nurse is caring for a client with Bell's palsy. Which of the following prescriptions should the nurse anticipate administering to the client?
Rationale:
Prednisone. This medication is an anti-inflammatory corticosteroid that helps reduce swelling and inflammation associated with Bell's palsy, promoting recovery of facial nerve function and alleviating associated symptoms effectively.
A: Modafinil. This stimulant is primarily used to treat sleep disorders and has no relevance in treating Bell's palsy or its associated symptoms.
C: Doxycycline. An antibiotic used to treat bacterial infections, doxycycline does not address the viral causes or inflammation linked to Bell's palsy.
D: Acyclovir. While effective against certain viral infections, it does not serve as a primary treatment for Bell's palsy, which is typically managed with corticosteroids like prednisone.
E: Sumatriptan. This medication is designed for migraine relief and does not target the inflammation or nerve impairment seen in Bell's palsy, making it unsuitable for this condition.
A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest?
Rationale:
A basilar skull fracture is suggested by the assessment finding. This type of fracture typically presents with specific signs, including periorbital ecchymosis and mastoid bruising, indicating potential trauma to the base of the skull.
A: CSF leak The signs of a CSF leak, such as clear fluid drainage or specific tests for glucose in fluid, are not evident in this case.
C: Brown-Sequard syndrome This condition involves hemisection of the spinal cord, presenting with specific neurological deficits, which are not indicated by the assessment findings here.
D: Subarachnoid hemorrhage Symptoms typically include sudden headache and possible neck stiffness, neither of which are highlighted in the assessment findings provided.
A client with Alzheimer's disease is eating in the dining hall along with the other clients. Thirty minutes later, he says to the nurse, 'When can I have my breakfast? They haven't given me anything to eat yet.' The most appropriate response for the nurse would be:
Rationale:
C: I can get you some bread if you like. What else would you like?
This response addresses the client’s immediate concern about hunger in a supportive manner, validating their feelings while offering a tangible solution. It encourages engagement and provides comfort, which is essential for individuals with Alzheimer's, who may struggle with memory and confusion about meal times.
A: I saw you eating breakfast 30 minutes ago. This statement may confuse or frustrate the client, as they may not recall the meal. Acknowledging their confusion without offering help is unhelpful.
B: Are you still not full? I'll ask the kitchen what they served you. While this option attempts to address the client’s hunger, it does not validate their feelings or provide immediate comfort, which is crucial.
D: You have to wait until it's lunchtime. This response dismisses the client’s current feelings of hunger and fails to provide reassurance or assistance, which is vital for their emotional well-being.