Nokea
The nurse cares for a client who sustained a stroke impacting the occipital lobe. Which of the following assessment findings would support this diagnosis?
- A. Homonymous hemianopia
- B. Impaired proprioception
- C. Expressive aphasia
- D. Impulsivity
Correct Answer: A
Rationale: Occipital lobe stroke commonly causes homonymous hemianopia due to visual cortex involvement.
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The nurse is planning a staff education program about seizures. It would be correct for the nurse to characterize complex partial seizures as
- A. A seizure that may cause syncope lasting for 1 to 3 minutes.
- B. A seizure where the individual remains conscious throughout the episode.
- C. A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion.
- D. A brief jerking or stiffening of the extremities that may occur singly or in groups.
Correct Answer: B
Rationale: Complex partial seizures involve impaired consciousness, not full consciousness.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. The nurse anticipates that the physician will prescribe which medications? Select all that apply.
- A. Prednisone
- B. Donepezil
- C. Pyridostigmine
- D. Valacyclovir
- E. Topiramate
Correct Answer: A,D
Rationale: Prednisone (a corticosteroid) reduces inflammation, and valacyclovir (an antiviral) addresses possible viral causes in Bell's palsy. Donepezil, pyridostigmine, and topiramate are not indicated.
The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a 15-year-old who has sustained a sports-related injury
Item 1 of 1
Triage Note Triage Vital Signs
1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
The nurse assigned to the client reviews the triage note and plans care
The nurse anticipates taking which action? Prepare the client for a computed tomography (CT) scan of the head
- A. Prepare the client for a computed tomography (CT) scan of the head
- B. Perform a Glasgow Coma Scale (GCS)
- C. Encourage by mouth (PO) fluids
- D. Assess the client's pupils
- E. Prepare the client for a lumbar puncture (LP)
Correct Answer: A,A,B,A,B
Rationale: A CT scan is indicated to assess for brain injury in a client with head trauma and loss of consciousness. GCS assessment is critical to evaluate neurological status post-head injury. Encouraging PO fluids is inappropriate until a CT scan rules out increased intracranial pressure. Pupil assessment is essential to detect neurological changes post-head trauma. Lumbar puncture is not indicated unless specific conditions like meningitis are suspected.
The nurse is supervising a graduate nurse implement seizure precautions for a client with epilepsy. Which observation by the nurse requires follow-up?
- A. Pads the side rails of the bed
- B. Lowers the side rails while the client sleeps.
- C. Removes hard and sharp objects from the bed.
- D. Places the client in four point restraints to prevent injury.
- E. Places a fall risk bracelet on the client.
Correct Answer: B,D
Rationale: Lowering side rails and using restraints increase injury risk during seizures and require correction.
The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. If I experience double-vision, I should put an eye patch on both eyes for a few hours.
- B. Planning my activities should help manage the fatigue.
- C. I should plan to take a hot bath for my muscle spasms.
- D. This disease may cause me to have an increased sensitivity to pain.
Correct Answer: B
Rationale: Planning activities helps manage fatigue, a common symptom in multiple sclerosis. Hot baths can worsen symptoms, and eye patches are used for one eye, not both.