Nokea
The nurse is assessing a client with suspected autonomic dysreflexia. Which assessment findings would support the diagnosis of autonomic dysreflexia?
- A. Severe headache
- B. Piloerection
- C. Hypotension
- D. Tachycardia
- E. Restlessness
Correct Answer: A,B,E
Rationale: Severe headache, piloerection, and restlessness are signs of autonomic dysreflexia due to sympathetic overactivity.
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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 receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.
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 RN is caring for a client who is recovering from carotid endarterectomy. Which assessment would the nurse recognize as a sign that the client experienced hypoglossal nerve injury?
- A. Tongue deviation
- B. Inspiratory stridor
- C. Tracheal deviation
- D. Severe headache
Correct Answer: A
Rationale: Hypoglossal nerve injury (cranial nerve XII) causes tongue deviation due to impaired tongue movement.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
- A. If my gums get irritated and large, I can stop this medication.
- B. I will need laboratory work to monitor the medication level.
- C. It is okay for me to increase this medication if I have a seizure.
- D. I should take this medication with low protein foods.
Correct Answer: B
Rationale: Phenytoin requires regular blood level monitoring to ensure therapeutic levels (10-20 mcg/mL). Stopping due to gum hyperplasia, increasing doses without medical advice, or taking with low-protein foods are incorrect.