Nokea
The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad?
- A. Hypotension, jugular venous distention, and muffled heart tones
- B. Irregular respirations, bradycardia, and widening pulse pressure
- C. Fixed pupils, hypotension, and bradycardia
- D. Bradycardia, hypotension, and bradypnea
Correct Answer: B
Rationale: Cushing's triad, indicative of increased intracranial pressure, includes irregular respirations, bradycardia, and widening pulse pressure.
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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.
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 reviewing laboratory data for a client taking prescribed phenytoin. The client's phenytoin level is 12 mcg/mL (10-20 mcg/mL). Which action should the nurse take next?
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for phenytoin toxicity
- D. Document the result as within normal limits
Correct Answer: D
Rationale: A phenytoin level of 12 mcg/mL is within the therapeutic range (10-20 mcg/mL), so the nurse should document the result as normal. Non-adherence, skipping doses, or toxicity assessment are not indicated.
The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
- A. Administer sublingual nitroglycerin.
- B. Elevate the head of the bed.
- C. Obtain a residual volume reading with a bladder scan.
- D. Perform a digital examination to assess for the presence of stool.
Correct Answer: B
Rationale: Elevating the head of the bed reduces blood pressure in autonomic dysreflexia.
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.