Nokea
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?
- A. Do you experience frequent bruising?'
- B. Did you have a recent respiratory or gastrointestinal infection?'
- C. Have you been overseas during the past four months?'
- D. Has anybody in your family had Guillain-Barré syndrome?'
Correct Answer: B
Rationale: Recent infections are a common trigger for Guillain-Barré syndrome.
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The nurse is planning a staff education program about seizures. It would be correct for the nurse to characterize complex partial seizures as
- A. A seizure that may cause syncope lasting for 1 to 3 minutes.
- B. A seizure where the individual remains conscious throughout the episode.
- C. A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion.
- D. A brief jerking or stiffening of the extremities that may occur singly or in groups.
Correct Answer: B
Rationale: Complex partial seizures involve impaired consciousness, not full consciousness.
Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain?
- A. Spinal tumor
- B. Arthritic joint
- C. Muscle strain
- D. Shingles
- E. Kidney stones
Correct Answer: A,D
Rationale: Spinal tumors and shingles cause neuropathic pain due to nerve involvement.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
- A. Peripheral artery disease
- B. Accelerated hypertension
- C. Migraine headache
- D. Angina
Correct Answer: C
Rationale: Sumatriptan is a triptan specifically used to treat migraine headaches by constricting blood vessels and reducing inflammation. It is not used for peripheral artery disease, hypertension, or angina.
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
- 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)
Correct Answer: A,A,B,A,B
Rationale: A CT scan is indicated to assess for brain injury in a client with head trauma and loss of consciousness. GCS assessment is critical to evaluate neurological status post-head injury. Encouraging PO fluids is inappropriate until a CT scan rules out increased intracranial pressure. Pupil assessment is essential to detect neurological changes post-head trauma. Lumbar puncture is not indicated unless specific conditions like meningitis are suspected.
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?
- A. Perform Semmes-Weinstein monofilament test
- B. Review the client's most recent blood glucose level
- C. Obtain a prescription for gabapentin
- D. Teach the client about appropriate footwear
Correct Answer: D
Rationale: Teaching about appropriate footwear prevents injuries in peripheral neuropathy by protecting insensate feet.