Nokea
The nurse is assessing a client taking prescribed lamotrigine. Which client finding requires immediate follow-up?
- A. Abnormal dreams
- B. Skin blistering
- C. Dyspepsia
- D. Xerostomia
Correct Answer: B
Rationale: Skin blistering is a serious adverse effect of lamotrigine, potentially indicating Stevens-Johnson syndrome or toxic epidermal necrolysis, both life-threatening conditions requiring immediate medical attention. Abnormal dreams, dyspepsia, and xerostomia are less severe side effects that do not typically require urgent follow-up.
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A 24-year old woman presents to the emergency department and appears as shown in the exhibit. What type of injury does this assessment finding suggest?
- A. CSF leak
- B. Basilar skull fracture
- C. Brown-Sequard syndrome
- D. Subarachnoid hemorrhage
Correct Answer: B
Rationale: Without the exhibit, basilar skull fracture is assumed due to context (e.g., raccoon eyes or CSF leak signs).
The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by:
- A. Fever
- B. Alzheimer's disease
- C. Hypoglycemia
- D. Vascular disease
- E. Infection
Correct Answer: A,C,E
Rationale: Fever, hypoglycemia, and infection are reversible causes of delirium, unlike Alzheimer's, which causes dementia.
The ICU nurse assesses a comatose patient with a known lesion to the medulla. Which breathing pattern would the nurse expect to assess?
- A. Cheyne-Stokes
- B. Apneustic breathing
- C. Central neurogenic hyperventilation
- D. Cluster breathing
Correct Answer: B
Rationale: Medulla lesions often cause apneustic breathing, characterized by prolonged inspiratory pauses.
The nurse is assessing a client with suspected neurogenic shock. Which of the following findings would support a diagnosis of neurogenic shock?
- A. Jugular vein distention
- B. Bradycardia
- C. Fever
- D. Bradypnea
Correct Answer: B
Rationale: Neurogenic shock is characterized by bradycardia due to loss of sympathetic tone.
The nurse observes a client with dementia not recognizing their family member. The nurse understands that this client is demonstrating signs of which of the following?
- A. Apraxia
- B. Agraphia
- C. Agnosia
- D. Aphasia
Correct Answer: C
Rationale: Agnosia is the inability to recognize familiar objects or people, common in dementia.