Nokea
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.
- A. Vomiting
- B. Altered blood coagulation
- C. Visual disturbances
- D. Drowsiness
- E. Aphasia
- F. Ataxia
Correct Answer: B,C,D,F
Rationale: Phenytoin may cause altered coagulation, visual disturbances, drowsiness, and ataxia, affecting safety and monitoring needs.
You may also like to solve these questions
A middle-aged client reports a sudden onset of seeing flashing lights and floating spots. Which is the best nursing action?
- A. Initiate a referral for ophthalmic evaluation as soon as possible.
- B. Advise the client to maintain normal activities, but avoid contact sports until the spots resolve
- C. Instruct the client to rest, and report to the emergency department if eye pain develops.
- D. Tell the client to apply warm, moist compresses and notify the healthcare provider if there is no improvement.
Correct Answer: A
Rationale: Flashing lights and floaters suggest retinal detachment, requiring urgent ophthalmic evaluation.
Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?
- A. Watch for shortness of breath which may indicate a fat embolus.
- B. Begin range of motion exercises within the first 24 hours.
- C. Apply ice intermittently for the first 24 hours.
- D. After edema subsides, apply heat continuously.
Correct Answer: C
Rationale: Intermittent ice reduces swelling and pain in acute soft tissue injuries, prioritizing over other instructions.
A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?
- A. I will lift weights every other day.'
- B. I will be able to stand as long as my legs do not hurt.'
- C. I will avoid sitting and crossing my legs.'
- D. I will need to get someone to walk my dog.'
Correct Answer: C
Rationale: Avoiding prolonged sitting and leg crossing improves venous return, aligning with chronic venous insufficiency management.
The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?
- A. Place protective padding between the client and bed rails.
- B. Provide privacy for the client during the event.
- C. Observe the client's behavior during the event.
- D. Record the client's level of consciousness after the event.
Correct Answer: A
Rationale: Padding prevents injury during a seizure, prioritizing client safety over privacy or observation.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
Exhibits
The nurse comes into the room to replace the IV bag and notices the client's extremities are jerking violently. The client is not arousable and the oxygen saturation is 59% on the monitor.
Based on the information collected, the client is likely experiencing [condition] related to [cause].
- A. Increased intracranial pressure
- B. Brain herniation
- C. Hypoxia
- D. Hypercapnia
- E. Absence seizure
- F. Decorticate posturing
- G. Tonic clonic seizure
Correct Answer: C,F
Rationale: Hypoxia from a tonic-clonic seizure causes low oxygen saturation and jerking movements, requiring urgent intervention.