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A nurse assesses a client who is at risk for secondary seizures. Which conditions place the client at risk? (Select all that apply.)
- A. Brain lesion from a tumor
- B. Metabolic disorder
- C. Acute alcohol withdrawal
- D. History of stroke
- E. Multiple sclerosis
Correct Answer: A,B,C,D
Rationale: Clients at risk for secondary seizures include those with brain lesions from tumors or trauma, metabolic disorders, acute alcohol withdrawal, electrolyte disturbances, high fever, stroke, or substance abuse. Multiple sclerosis and chronic pulmonary disease are not typically associated with secondary seizures.
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A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
- A. Lip smacking
- B. Sudden loss of muscle tone
- C. Brief jerking of the extremities
- D. Picking at clothing
- E. Staring spell
Correct Answer: A,D,E
Rationale: Absence seizures are characterized by brief lapses in attention, often with staring spells, lip smacking, or picking at clothing. Sudden loss of muscle tone is more typical of atonic seizures, and brief jerking of extremities is associated with myoclonic seizures.
A nurse assesses a client after administering prescribed levetrincatam (Kepprna). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?
- A. Serum electrolyte levels
- B. Kidney function tests
- C. Complete blood cell count
- D. Liver function tests
Correct Answer: B
Rationale: Adverse effects of levetiracetam (Keppra) include coordination problems and renal toxicity. Kidney function tests should be monitored to detect potential adverse effects. The other laboratory tests are not typically affected by levetiracetam.
A nurse cares for a client with advanced Alchimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
- A. This is a sign of fatigue. The client would benefit from a daily nap.
- B. Engage the client in scheduled activities throughout the day.
- C. It sounds like this is difficult for you. I will consult the social worker.
- D. The provider can prescribe a mild sedative for restlessness.
Correct Answer: B
Rationale: Several strategies may be used to cope with restlessness and wandering in Alzheimer's disease. Engaging the client in structured activities throughout the day is effective. Daily naps and sedatives are less effective, and consulting a social worker does not directly address the behavior.
A nurse is teaching a client who experiences migraine headaches. Which statement should the nurse include in the teaching to help prevent the onset of migraine headaches?
- A. Wear dark sunglasses when you are in brightly lit spaces.
- B. Lie down in a darkened room when you experience a headache.
- C. Set your alarm to ensure you do not sleep longer than 6 hours at one time.
- D. Take over-the-counter pain relievers as soon as the headache starts.
Correct Answer: B
Rationale: At the onset of a migraine attack, lying down in a darkened room can alleviate pain. The client may cover both eyes and use a cool cloth on the forehead. If the client falls asleep, they should remain undisturbed. The other options are not recognized therapies for migraines.
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
- A. Sodium levels
- B. Clotting factors
- C. White blood cell count
- D. C-reactive protein
- E. Liver enzymes
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.