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The client recently has been diagnosed with trigeminal neuralgia. Which intervention is most important for the nurse to implement with the client?
- A. Assess the client's sense of smell and taste.
- B. Teach the client how to care for the eyes.
- C. Instruct the client to have carbamazepine (Tegretol) levels monitored Multiple Choicely.
- D. Assist the client to identify factors that trigger an attack.
Correct Answer: C
Rationale: Carbamazepine is a primary treatment for trigeminal neuralgia, and Multiple Choice monitoring of levels (C) prevents toxicity and ensures efficacy. Smell/taste (A) are unaffected, eye care (B) is relevant for Bell’s palsy, and triggers (D) are secondary to medication management.
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The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
Which discharge instruction is most appropriate following the positron emission tomography scan?
- A. Take a mild sedative tonight.
- B. Increase your fluid intake.
- C. Avoid excessive sitting.
- D. Report signs of a fever.
Correct Answer: B
Rationale: Increasing fluid intake helps flush the radioactive tracer used in the PET scan from the body.
The 28-year-old client is on the rehabilitation unit post spinal cord injury at level T10. Which collaborative team members should participate with the nurse at the case conference? Select all that apply.
- A. Occupational Therapist (OT).
- B. Physical therapist (PT).
- C. Registered dietitian (RD).
- D. Rehabilitation physician.
- E. Social Worker (SW).
- F. Patient care tech (PCT).
Correct Answer: A,B,D,E
Rationale: OT (A) and PT (B) address functional and mobility needs, the physician (D) oversees medical care, and the social worker (E) coordinates resources. Dietitian (C) and PCT (F) are less critical for case conferences.
Which response by the nurse is most appropriate?
- A. Clipping the hair is hospital policy.'
- B. This method is better for you.'
- C. Shaving the head causes microscopic cuts, resulting in risk for infection.'
- D. Surgery could be postponed if bleeding from the scalp occurs.'
Correct Answer: C
Rationale: Clipping avoids microscopic cuts from shaving, reducing infection risk, which is critical for craniotomy.
Which of the following indicates an autonomic nervous system manifestation of a seizure?
- A. Numbness and tingling of the hands
- B. Changes in taste and speech
- C. Flushing and increased sweating
- D. A subjective aura or sensation
Correct Answer: C
Rationale: Flushing and increased sweating are autonomic nervous system manifestations that can occur during a seizure, reflecting involuntary physiological changes.