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The following scenario applies to the next 1 items
The emergency department nurse is caring for a 27-year-old male client.
Item 1 of 1
Nurses' Notes
1500: Client reports an 'excruciating' headache right behind his left eye. He says the pain is 'pulsating' and worse when lying down. He reports sensitivity to lights and sounds. He reports getting these headaches daily for the past two weeks at about the same time. He states that the headache lasts one to two hours. On assessment, the client appears in moderate distress; he is alert, oriented, and has tearing in his left eye. His gait was steady as he paced around the exam room because having him sit down to obtain vital signs increased his pain. Lung sounds are clear; peripheral pulses were 2+. Normoactive bowel sounds. He reports his pain rated 9/10 on the Numerical Rating Scale.
The client is demonstrating clinical manifestations consistent with
- A. Cluster headache
- B. Tension headache
- C. Trigeminal neuralgia
- D. Migraine headache
Correct Answer: A
Rationale: The symptoms (excruciating unilateral headache, tearing, sensitivity to light/sound) are characteristic of cluster headaches.
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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 performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.
The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
- A. Obtain an accurate weight
- B. Insert two peripheral vascular access devices
- C. Insert a nasogastric tube (NGT) immediately after alteplase infusion
- D. Obtain baseline laboratory work (CBC, CMP, aPTT, PT/INR) prior to infusion of alteplase
- E. Plan for admission to the medical-surgical floor
- F. Perform frequent neurological assessments
- G. Notify the physician if the systolic blood pressure is 185 mm Hg or greater
Correct Answer: A,A,B,A,B,A
Rationale: Accurate weight is critical for calculating the correct dose of alteplase for stroke treatment. Two peripheral IVs are needed for alteplase administration to ensure reliable access for the thrombolytic and other medications. NGT insertion is not immediately indicated post-alteplase unless swallowing difficulties are confirmed, to avoid complications. Baseline labs are essential to assess bleeding risk before administering thrombolytics like alteplase. Stroke patients receiving alteplase typically require ICU admission for close monitoring, not a medical-surgical floor. Frequent neurological assessments are critical post-alteplase to monitor for neurological changes or complications.
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 Bell's palsy. Which of the following prescriptions should the nurse anticipate administering to the client?
- A. Modafinil
- B. Prednisone
- C. Doxycycline
- D. Acyclovir
- E. Sumatriptan
Correct Answer: B,D
Rationale: Prednisone reduces inflammation, and acyclovir treats potential viral causes in Bell's palsy.