Nokea
The nurse is assessing a client receiving prescribed donepezil. Throughout the duration of therapy, the nurse should monitor the client's
- A. Pulse
- B. Fasting blood glucose
- C. Total cholesterol
- D. Pulse oximetry
Correct Answer: A
Rationale: Donepezil, a cholinesterase inhibitor for Alzheimer's, can cause bradycardia due to increased vagal tone. Monitoring pulse is essential. Blood glucose, cholesterol, and pulse oximetry are not typically affected.
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The nurse is assessing a client with suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
- A. Respiratory acidosis
- B. Thready peripheral pulses
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis is a sign of neurogenic shock due to loss of sympathetic tone.
The following scenario applies to the next 1 items
The nurse cares for a 75-year-old client who arrives at the emergency department
Item 1 of 1
History And Physical
Vital Signs
1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress: Condition
- A. Transport the client for computed tomography (CT) scan
- B. Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
- C. Complex Migraine
- D. Severe Hypoglycemia
- E. Cerebral Vascular Accident
- F. Vital Signs
- G. Glasgow Coma Scale (GCS)
Correct Answer: A,B,E,F,G
Rationale: Symptoms (facial droop, hemiparesis, aphasia) indicate a stroke (CVA). CT scan and lab work are critical for stroke diagnosis and thrombolytic eligibility. GCS and vital signs monitor neurological and hemodynamic status in stroke.
The nurse is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
- A. Abrupt onset
- B. Change in psychomotor activity
- C. Irreversible
- D. Progressively worsens
- E. Decreased attention and awareness
- F. Fluctuating level of consciousness
Correct Answer: A,B,E,F
Rationale: Delirium is characterized by abrupt onset, changes in psychomotor activity, decreased attention, and fluctuating consciousness. It is reversible, unlike dementia.
The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain?
- A. Respiratory rate
- B. Blood Pressure
- C. Pulse
- D. Temperature
Correct Answer: A
Rationale: Cervical spinal cord injury can impair respiratory function, making respiratory rate the priority.
The nurse is planning care for a client with homonymous hemianopia. The nurse should plan for which intervention in the care plan?
- A. Place an eye patch over the affected eye
- B. Instruct the client to turn their head from side to side
- C. Speak slowly, clearly, and in a deeper voice
- D. Provide the client with ear plugs to promote rest
Correct Answer: B
Rationale: Head turning compensates for the visual field loss in homonymous hemianopia.