Nokea
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?
- A. Supination
- B. Dorsiflexion
- C. Hyperextension
- D. Abduction
Correct Answer: B
Rationale: Dorsiflexion prevents foot drop by maintaining proper foot alignment.
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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.
- A. Migraine headache
- B. Guillain-Barré syndrome
- C. Meningitis
- D. Delirium
- E. Alzheimer's disease
- F. Parkinson's disease
Correct Answer: A,C
Rationale: Photophobia is a common symptom in migraine headaches and meningitis due to neurological sensitivity and inflammation, respectively. Guillain-Barré syndrome, delirium, Alzheimer's, and Parkinson's do not typically cause photophobia.
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?
- A. Observe the client during meals
- B. Keep suction at the bedside
- C. Provide large print education materials
- D. Teach the client to scan the room
- E. Alternate the use of an eye patch
Correct Answer: A,B
Rationale: Hypoglossal nerve impairment affects tongue movement, increasing choking risk, necessitating meal observation and suction availability.
The nurse is assessing a client receiving prescribed donepezil. Throughout the duration of therapy, the nurse should monitor the client's
- A. Pulse
- B. Fasting blood glucose
- C. Total cholesterol
- D. Pulse oximetry
Correct Answer: A
Rationale: Donepezil, a cholinesterase inhibitor for Alzheimer's, can cause bradycardia due to increased vagal tone. Monitoring pulse is essential. Blood glucose, cholesterol, and pulse oximetry are not typically affected.
In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia?
- A. Hypotension
- B. Sudden headache
- C. Flushed face
- D. Nasal congestion
- E. Profuse sweating above the level of the injury
Correct Answer: B,C,D,E
Rationale: Autonomic dysreflexia causes headache, flushing, nasal congestion, and sweating above the injury level due to sympathetic overactivity.
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?
- A. Glucose
- B. Weight
- C. Creatinine
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: Rivastigmine, a cholinesterase inhibitor, can cause gastrointestinal side effects such as nausea, vomiting, and weight loss. Monitoring weight is essential to assess for significant weight loss, which can impact the client's health. Glucose, creatinine, and hemoglobin/hematocrit are not typically affected by rivastigmine.