Nokea
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.
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The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
- A. Place an eye patch over the affected eye
- B. Instruct the client to turn their head from side to side
- C. Speak slowly, clearly, and in a deeper voice
- D. Provide the client with ear plugs to promote rest
Correct Answer: B
Rationale: Head turning compensates for the visual field loss in homonymous hemianopia.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. The nurse anticipates that the physician will prescribe which medications? Select all that apply.
- A. Prednisone
- B. Donepezil
- C. Pyridostigmine
- D. Valacyclovir
- E. Topiramate
Correct Answer: A,D
Rationale: Prednisone (a corticosteroid) reduces inflammation, and valacyclovir (an antiviral) addresses possible viral causes in Bell's palsy. Donepezil, pyridostigmine, and topiramate are not indicated.
The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. If I experience double-vision, I should put an eye patch on both eyes for a few hours.
- B. Planning my activities should help manage the fatigue.
- C. I should plan to take a hot bath for my muscle spasms.
- D. This disease may cause me to have an increased sensitivity to pain.
Correct Answer: B
Rationale: Planning activities helps manage fatigue, a common symptom in multiple sclerosis. Hot baths can worsen symptoms, and eye patches are used for one eye, not both.
The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for VPA toxicity
- D. Document the result as within normal limits
Correct Answer: A
Rationale: A VPA level of 40 mcg/mL is below the therapeutic range (50-125 mcg/mL), suggesting possible non-adherence to the prescribed regimen. Skipping a dose is inappropriate, toxicity is unlikely with a low level, and the result is not within normal limits.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 1 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Which of the following assessment findings require immediate follow-up?
- A. Neurological assessment findings
- B. Pulse and temperature
- C. Gastrointestinal assessment findings
- D. Influenza vaccination status
- E. Daily smoking habit
- F. Blood pressure and pulse oximetry reading
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.