Nokea
The nurse is assessing a client with Guillain-Barré syndrome. Which of the following would be an expected finding?
- A. Hyperreflexia
- B. Perseveration
- C. Dystonia
- D. Paresthesia
Correct Answer: D
Rationale: Paresthesia (tingling/numbness) is common in Guillain-Barré syndrome due to peripheral nerve demyelination.
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The nurse is caring for an older adult client with delirium for the third time in the past four months. While reviewing the client's medical record to determine the cause, the nurse should prioritize reviewing the client's
- A. Vital signs
- B. Height and weight
- C. Family medical history
- D. Current medications
Correct Answer: D
Rationale: Medications are a common reversible cause of recurrent delirium in the elderly.
The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?
- A. Prepares to administer intravenous valproate.
- B. Place the client in a lateral position.
- C. Activates the rapid response team (RRT).
- D. Loosens any restrictive clothing.
Correct Answer: A
Rationale: Valproate is not a first-line treatment for status epilepticus; benzodiazepines like lorazepam are preferred.
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 evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
- A. The client can control the motorized wheelchair.
- B. The client states she wants to stand up with assistance.
- C. The client says she wants to move her toes.
- D. The client says she regained her bladder control.
Correct Answer: A
Rationale: Controlling a motorized wheelchair indicates improved upper body function, appropriate for C6-C7 injury.
The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for VPA toxicity
- D. Document the result as within normal limits
Correct Answer: A
Rationale: A VPA level of 40 mcg/mL is below the therapeutic range (50-125 mcg/mL), suggesting possible non-adherence to the prescribed regimen. Skipping a dose is inappropriate, toxicity is unlikely with a low level, and the result is not within normal limits.