Nokea
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.
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The nurse is caring for a client diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which medication?
- A. Topiramate
- B. Risperidone
- C. Prazosin
- D. Baclofen
Correct Answer: D
Rationale: Baclofen is a muscle relaxant commonly prescribed for spasticity in Multiple Sclerosis. Topiramate is used for seizures or migraines, risperidone for psychiatric conditions, and prazosin for hypertension, none of which are primary treatments for MS.
The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?
- A. Confusion
- B. Disorientation
- C. Agitation
- D. Delirium
- E. Hypervigilance
Correct Answer: A,B,C,D,E
Rationale: These findings (confusion, disorientation, agitation, delirium, hypervigilance) are all indicative of altered mental status, often seen in elderly patients with infections like pneumonia due to physiological stress or hypoxia.
The primary healthcare provider (PHCP) is preparing to intubate a client. The PHCP prescribes succinylcholine. The nurse understands that this medication is intended to
- A. Sedate the client during the procedure
- B. Decrease oral and airway secretions
- C. Increase heart rate in case of a vagal response
- D. Cause skeletal muscle paralysis
Correct Answer: D
Rationale: Succinylcholine is a depolarizing neuromuscular blocker used to cause skeletal muscle paralysis, facilitating intubation. It does not sedate, reduce secretions, or increase heart rate.
The nurse is developing a plan of care for a client with advanced Alzheimer's disease. Which of the following should the nurse include?
- A. Assess the client's risk for falls
- B. Monitor the client for hyperorality
- C. Provide consistent caregivers
- D. Obtain a prescription for as-needed (PRN) diphenhydramine
- E. Foster a low-stimulation environment
- F. Offer limited choices
Correct Answer: A,B,C,E,F
Rationale: These interventions address safety, behavior, and comfort in advanced Alzheimer's disease.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 6 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
• Diagnostics Test Results
Head Computed Tomography (CT) scan
1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes.
• Nurses' Notes
1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.
1850: Pain reassessed. Client reports pain 7/10 on the Numerical Rating Scale. Reports persistent nausea.
1852: Physician notified of the findings.
• Orders
1800:
• ketorolac 30 mg intravenous push x 1 dose
• 500 mL of 0.9% sodium chloride (normal saline) over one hour
1900:
• metoclopramide 10 mg intravenous push x 1 dose
• diphenhydramine 25 mg intravenous push x 1 dose
• sumatriptan 6 mg subcutaneous x1 dose
Six hours later, the client recovers and is discharged home. The nurse is teaching the client about newly prescribed intranasal sumatriptan. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. I should use this medication as soon as I notice migraine symptoms beginning.
- B. If my migraine does not improve after two hours, I can take a second dose, but no more than 40 mg in 24 hours.
- C. I should avoid using this medication if I experience chest pain or pressure after taking it.
- D. I can use this medication daily to prevent migraines from occurring.
- E. If I experience tingling or flushing after taking this medication, I should go to the emergency room.
- F. I should watch for signs of serotonin syndrome, such as confusion and muscle stiffness.
Correct Answer: A,B,C
Rationale: Using sumatriptan at migraine onset, redosing after 2 hours (with a 40 mg daily limit for intranasal form), and avoiding use with chest pain (due to possible coronary vasospasm) are correct. Daily use is incorrect (sumatriptan is for acute treatment), tingling/flushing are common side effects, and serotonin syndrome is unlikely with sumatriptan alone.