Nokea
Select the three (3) prescriptions/orders the nurse should anticipate for this client
- A. Computed tomography scan of the brain
- B. Capillary blood glucose
- C. Lumbar puncture
- D. Arterial blood gas (ABG)
- E. Heparin by continuous IV infusion
- F. Nothing by mouth (NPO) status
- G. 500 mL of 0.9% saline
Correct Answer: A,B,F
Rationale: CT scan, CBG, and NPO status are critical for suspected stroke to assess brain injury, rule out hypoglycemia, and prepare for possible thrombolytics.
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The nurse is caring for a client receiving intravenous (IV) alteplase for a cerebrovascular accident (CVA). The nurse understands that this medication has reached its therapeutic effect when the client is assessed to have
- A. Increase in the Glasgow Coma Scale
- B. Unintelligible speech
- C. Bleeding at their gum line
- D. Increase in pulse and decrease in blood pressure
Correct Answer: A
Rationale: Alteplase is a thrombolytic used to dissolve clots in acute ischemic stroke, improving neurological function, as indicated by an increased Glasgow Coma Scale. Unintelligible speech, bleeding, and vital sign changes are not therapeutic effects.
The emergency department (ED) nurse triages a client with suspected bacterial meningitis. The nurse plans on assessing the client for Kernig's sign. The nurse understands that this sign is positive when the client?
- A. Reports pain when the knee is extended and the hip flexed.
- B. Has a stiff neck when the neck is flexed towards the chest.
- C. Forearm spasms when a blood pressure cuff is inflated on the upper arm.
- D. Reports pain in the calf when the foot is dorsiflexed.
Correct Answer: A
Rationale: Kernig's sign is positive when hip flexion with knee extension causes pain, indicating meningitis.
The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected?
- A. Halitosis
- B. Chorea
- C. Hallucinations
- D. Hematemesis
- E. Weight loss
Correct Answer: B,E
Rationale: Chorea (involuntary movements) and weight loss are hallmark symptoms of Huntington's disease.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Presbycusis
- B. Ototoxic substance
- C. Foreign body
- D. Exposure to loud noise
- E. Edema
Correct Answer: A,B,D
Rationale: Presbycusis, ototoxic substances, and loud noise exposure cause sensorineural hearing loss by damaging the inner ear or auditory nerve.
The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by:
- A. Fever
- B. Alzheimer's disease
- C. Hypoglycemia
- D. Vascular disease
- E. Infection
Correct Answer: A,C,E
Rationale: Fever, hypoglycemia, and infection are reversible causes of delirium, unlike Alzheimer's, which causes dementia.