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A patient has a tonic-clonic seizure while the nurse is in the patient's room. Which of the following actions should the nurse take?
- A. Insert an oral airway during the seizure to maintain a patent airway.
- B. Restrain the patient's arms and legs to prevent injury during the seizure.
- C. Avoid touching the patient to prevent further nervous system stimulation.
- D. Time and observe and record the details of the seizure and postictal state.
Correct Answer: D
Rationale: Because diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
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A female patient who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which of the following responses by the nurse is accurate?
- A. MS symptoms may be worse after the pregnancy.
- B. Women with MS frequently have premature labour.
- C. Symptoms of MS are likely to become worse during pregnancy.
- D. MS is associated with a slightly increased risk for congenital defects.
Correct Answer: A
Rationale: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labour is not affected by MS.
The nurse is caring for a patient with Parkinson's disease who has decreased tongue mobility and an inability to move the facial muscles. Which of the following nursing diagnoses is of highest priority?
- A. Activity intolerance related to immobility
- B. Toileting self-care deficit related to impaired mobility
- C. Ineffective health management related to difficulty managing complex treatment regimen
- D. Imbalanced nutrition: less than body requirements related to insufficient dietary intake
Correct Answer: D
Rationale: The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses also may be appropriate for a patient with Parkinson's disease, but the data do not indicate they are current problems for this patient.
The nurse is caring for a patient with Parkinson's disease who is admitted to the hospital for treatment of an acute infection. Which of the following nursing interventions will be included in the plan of care? (Select all that apply.)
- A. Use an elevated toilet seat.
- B. Cut patient's food into small pieces.
- C. Provide high protein foods at each meal.
- D. Place an arm chair at the patient's bedside.
- E. Observe for sudden exacerbation of symptoms.
Correct Answer: A,B,D
Rationale: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.
A patient was noted to have a generalized seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. What type of seizure would this be classified as?
- A. Atonic
- B. Partial
- C. Absence
- D. Myoclonic
Correct Answer: B
Rationale: The initial symptoms of a partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.
Which action will the nurse take when evaluating a patient who is taking phenytoin for adverse effects of the medication?
- A. Inspect the oral mucosa.
- B. Listen to the lung sounds.
- C. Auscultate the bowel tones.
- D. Check pupil reaction to light.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.