Nokea
The client is admitted to the intensive care unit (ICU) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?
- A. Assess the client’s neurological status every hour.
- B. Monitor the client’s heart rhythm via telemetry.
- C. Administer an anticonvulsant medication by intravenous push.
- D. Prepare to administer a glucocorticosteroid orally.
Correct Answer: C
Rationale: Status epilepticus is a life-threatening continuous seizure requiring immediate IV anticonvulsants (C), such as lorazepam or phenytoin, to stop the seizure. Neurological assessment (A) and telemetry (B) are supportive, and glucocorticoids (D) are not indicated.
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The client newly diagnosed with Parkinson’s Disease (PD) asks the nurse, 'Why can’t I control these tremors?' Which is the nurse’s best response?
- A. You can control the tremors when you learn to concentrate and focus on the cause.'
- B. The tremors are caused by a lack of the chemical dopamine in the brain; medication may help.'
- C. You have too much acetylcholine in your brain causing the tremors but they will get better with time.'
- D. You are concerned about the tremors? If you want to talk I would like to hear how you feel.'
Correct Answer: B
Rationale: Parkinson’s tremors result from dopamine deficiency (B), and medications like levodopa help. Concentration (A) doesn’t control tremors, acetylcholine imbalance (C) is partial and not time-resolving, and reflection (D) doesn’t answer the question.
Which problem is the highest priority for the client diagnosed with West Nile virus?
- A. Alteration in body temperature.
- B. Altered tissue perfusion.
- C. Fluid volume excess.
- D. Altered skin integrity.
Correct Answer: A
Rationale: Fever (alteration in body temperature, A) is a primary symptom of West Nile virus, requiring priority management to prevent complications. Perfusion (B), fluid excess (C), and skin integrity (D) are less immediate.
The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse’s conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply.
- A. Blurred vision
- B. BP 198/102 mm Hg
- C. Heart rate 150 bpm
- D. Extreme headache
- E. Sweaty face and arms
Correct Answer: A,B,D,E
Rationale: Blurred vision results from the hypertension occurring with autonomic dysreflexia. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. Headache results from the hypertension occurring with autonomic dysreflexia. Sweating results from the sympathetic stimulation above the level of injury.
The client being monitored while receiving tissue plasminogen activator (tPA) following an ischemic stroke opens both eyes spontaneously, mumbles inappropriate words in response to orientation questions, has no ability to move any extremities, and has decerebrate posturing in response to nailbed pressure. Based on the chart illustrated, what is the client’s Glasgow Coma Scale (GCS) score?
- A. 9 GCS score
Correct Answer: 9
Rationale: Spontaneous eye opening is scored as 4; the best verbal response of inappropriate words is scored as 3, and the best motor response of decerebrate posturing is scored as 2.
Which assessment finding is most important to consider before developing the client's care plan?
- A. The client's ability to perform activities of daily living
- B. The client's preferences for and dislikes of various foods
- C. The family members' views about nursing home placement
- D. The client's feelings about giving up independent living
Correct Answer: A
Rationale: The ability to perform ADLs determines the level of assistance needed, guiding the care plan for a client with Parkinson's disease.