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A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
- A. If my gums get irritated and large, I can stop this medication.
- B. I will need laboratory work to monitor the medication level.
- C. It is okay for me to increase this medication if I have a seizure.
- D. I should take this medication with low protein foods.
Correct Answer: B
Rationale: Phenytoin requires regular blood level monitoring to ensure therapeutic levels (10-20 mcg/mL). Stopping due to gum hyperplasia, increasing doses without medical advice, or taking with low-protein foods are incorrect.
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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?
- A. The client and their family members will arrange for rehabilitation.
- B. The rehabilitation plan should be implemented early in the client's treatment.
- C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities.
- D. Long-term care should be arranged, as the client can no longer perform self-care.
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.
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 caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.
The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply.
- A. Topiramate
- B. Risperidone
- C. Prazosin
- D. Hydroxyzine
- E. Lorazepam
Correct Answer: A,E
Rationale: Topiramate and lorazepam are used for epilepsy (topiramate for seizure prevention, lorazepam for acute seizures). Risperidone, prazosin, and hydroxyzine are not indicated for epilepsy.
A client presents to the emergency department with symptoms of muscle weakness, double vision, and difficulty swallowing. The nurse suspects botulism poisoning. Which of the following statements accurately describes botulism?
- A. Botulism is caused by a bacterial infection with Clostridium difficile.
- B. Botulism is primarily transmitted through contaminated water sources.
- C. Botulism toxin acts by enhancing muscle contractions and reflexes.
- D. Botulism toxin inhibits the release of acetylcholine at neuromuscular junctions.
Correct Answer: D
Rationale: Botulism toxin inhibits acetylcholine release, causing muscle weakness.