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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?
- A. Keeping the client's room dimly lit to minimize visual stimulation
- B. Administer antiepileptic medications as prescribed.
- C. Implement seizure precautions, including padded side rails up and the bed in the lowest position.
- D. Provide education to the client and family about seizure triggers and safety measures.
Correct Answer: C
Rationale: Seizure precautions directly reduce injury risk during a seizure by ensuring a safe environment.
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The nurse is caring for a client with Bell's palsy. Which of the following prescriptions should the nurse anticipate administering to the client?
- A. Modafinil
- B. Prednisone
- C. Doxycycline
- D. Acyclovir
- E. Sumatriptan
Correct Answer: B,D
Rationale: Prednisone reduces inflammation, and acyclovir treats potential viral causes in Bell's palsy.
The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.
The following scenario applies to the next 1 items
A client presents to the clinic with reports of difficulty with their vision
Item 1 of 1
Nurses' Notes
Diagnostics
A 63-year-old male presents with concerns about difficulty with driving at nighttime. The client states, '1 feel like my vision is blurred, and I cannot change it.' The client reports no pain in either eye. He reports that this problem has 'gotten worse and cannot drive anymore because it is hard to see at night' and it started 'some time ago' and cannot pinpoint an exact start. The assessment showed the pupils were equal, round, and briskly reactive to light. They measured 3 mm. Slight opacity was noted in both eyes. No loss in the visual fields.
The nurse reviews the assessment findings
Click to specify if the assessment findings are consistent with cataracts or glaucoma: Increase in intraocular pressure (IOP)
- A. Vision impairment worse at nighttime
- B. Opacity in the eye
- C. Blurred vision
- D. Increase in intraocular pressure (IOP)
Correct Answer: A,A,A,B
Rationale: Increased IOP is characteristic of glaucoma.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 1 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 is assessing the client with a persistent headache. Which two (2) findings from the client's history and physical examination are most concerning and require immediate intervention?
- A. Headache described as throbbing and located behind the left eye
- B. Visual disturbances, including flashes of light and blurred vision
- C. Confusion and difficulty speaking
- D. Persistent nausea despite normoactive bowel sounds
- E. Use of escitalopram and buspirone for generalized anxiety disorder
- F. Right arm weakness
Correct Answer: C,F
Rationale: Confusion, difficulty speaking, and right arm weakness suggest a possible stroke or other serious neurological condition, requiring immediate intervention. Throbbing headache, visual disturbances, nausea, and medication use are less urgent.
The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?
- A. Active range of motion in both arms
- B. Scant drainage on the dressing
- C. Difficulty swallowing liquids
- D. Soreness at the operative site
Correct Answer: C
Rationale: Difficulty swallowing (dysphagia) post-cervical spinal surgery could indicate complications like nerve damage or swelling, requiring immediate follow-up.