Nokea
The emergency department (ED) nurse cares for a client with a suspected cerebrovascular accident (CVA). Which actions should the nurse take?
- A. Perform a Glasgow coma scale (GCS)
- B. Assess the client's capillary blood glucose (CBG)
- C. Prepare the client for an immediate computed tomography (CT) scan of the brain
- D. Insert a nasogastric tube (NGT)
- E. Determine the onset of the symptoms or the last known well (LKW)
Correct Answer: A,B,C,E
Rationale: GCS, CBG, CT scan, and determining symptom onset are critical for stroke assessment and management.
You may also like to solve these questions
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
- A. Increased ability to focus
- B. Decreased muscle spasms
- C. Improved short-term memory
- D. Sleeping without awakening at night
Correct Answer: B
Rationale: Tizanidine is a muscle relaxant used to treat spasticity. A therapeutic effect is indicated by decreased muscle spasms. Increased focus, improved memory, and better sleep are not primary effects of tizanidine.
The nurse is caring for a client with peripheral neuropathy of the lower extremities. Which intervention would be appropriate to prevent injury to the client's feet?
- A. Perform Semmes-Weinstein monofilament test
- B. Review the client's most recent blood glucose level
- C. Obtain a prescription for gabapentin
- D. Teach the client about appropriate footwear
Correct Answer: D
Rationale: Teaching about appropriate footwear prevents injuries in peripheral neuropathy by protecting insensate feet.
The nurse is caring for a client diagnosed with epilepsy. The nurse should anticipate a prescription for which of the following medications? Select all that apply.
- A. Topiramate
- B. Risperidone
- C. Prazosin
- D. Hydroxyzine
- E. Lorazepam
Correct Answer: A,E
Rationale: Topiramate and lorazepam are used for epilepsy (topiramate for seizure prevention, lorazepam for acute seizures). Risperidone, prazosin, and hydroxyzine are not indicated for epilepsy.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
- A. Peripheral artery disease
- B. Accelerated hypertension
- C. Migraine headache
- D. Angina
Correct Answer: C
Rationale: Sumatriptan is a triptan specifically used to treat migraine headaches by constricting blood vessels and reducing inflammation. It is not used for peripheral artery disease, hypertension, or angina.
The nurse is caring for a client with a concussion. Which assessment finding indicates that the client is experiencing a complication?
- A. Reports of a persistent headache
- B. Glasgow Coma Scale 13
- C. Heart rate 56
- D. Drowsiness
Correct Answer: C
Rationale: Bradycardia (heart rate 56) suggests increased intracranial pressure, a concussion complication.