Nokea
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.
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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.
The primary healthcare provider (PHCP) is preparing to intubate a client. The PHCP prescribes succinylcholine. The nurse understands that this medication is intended to
- A. Sedate the client during the procedure
- B. Decrease oral and airway secretions
- C. Increase heart rate in case of a vagal response
- D. Cause skeletal muscle paralysis
Correct Answer: D
Rationale: Succinylcholine is a depolarizing neuromuscular blocker used to cause skeletal muscle paralysis, facilitating intubation. It does not sedate, reduce secretions, or increase heart rate.
The following scenario applies to the next 1 items
The outpatient clinic nurse cares for a 40-year-old female client.
Item 1 of 1
Nurses' Notes
1450: Client reports to the clinic with her daughter because of various concerning symptoms that started about eight months ago. The client's daughter has noticed that her mother has become increasingly clumsy and uncoordinated. She reports that she is tripping over her own feet, which has caused her to fall twice. The client's daughter also reports becoming emotionally labile for 'no apparent reason.' The client reports that she gets 'spells of double vision that lasts for a few days' that seem to worsen with the heat. The client's daughter is concerned because her mother is not the 'get up and go' type of woman she used to be. The client does endorse generalized fatigue that worsens as the day progresses. In fact, she states
She goes to bed early because she gets so tired by 6 pm. The client says that two weeks ago, her vision doubled so much that she purchased an eye patch at the drugstore, which did help. Her daughter reports checking on her mother; her language was garbled and unrecognizable. She was almost ready to take her to the ED because she thought she was having a stroke. Finally, the client provided documentation from two urgent care visits in the past six months because of urinary tract infections. The client indicates she has had urinary problems dealing with urgency. She states that she has no pain, and in fact, she has difficulty determining if she has a UTI because she has decreased sensation in her pelvic region, which she cannot explain. On assessment, the client's breathing is unlabored, and breath sounds are clear bilaterally. Skin warm to touch with no tenting; bruising noted on the client's shins; pulses 2+ and regular. Capillary refill is 3 seconds. The client is alert and oriented to person, place, and situation. She currently takes no medications and has a medical history of uterine fibroids.
For each client finding below, click to specify if the finding is consistent with the disease process of Parkinson's disease, myasthenia gravis, or multiple sclerosis:
- A. Diplopia
- B. Emotional lability
- C. generalized fatigue
- D. Muscle incoordination
- E. diminished response to pain
- F. heat sensitivity
- G. urinary urgency
Correct Answer: B,C,A,C
Rationale: Diplopia is common in myasthenia gravis (due to ocular muscle weakness) and multiple sclerosis (due to optic nerve involvement). Emotional lability is a hallmark of multiple sclerosis due to demyelination affecting emotional regulation. Fatigue is common in myasthenia gravis (muscle fatigability) and multiple sclerosis (due to neurological dysfunction).
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Drowsiness
- C. Photophobia
- D. Shuffling gait
- E. Dysphagia
- F. Vomiting
Correct Answer: A,C,F
Rationale: Unilateral pain, photophobia, and vomiting are typical migraine symptoms.
A nurse is caring for a client with a history of seizures who is at risk for injury. Which intervention is the highest priority to reduce the client's risk of injury?
- A. Keeping the client's room dimly lit to minimize visual stimulation
- B. Administer antiepileptic medications as prescribed.
- C. Implement seizure precautions, including padded side rails up and the bed in the lowest position.
- D. Provide education to the client and family about seizure triggers and safety measures.
Correct Answer: C
Rationale: Seizure precautions directly reduce injury risk during a seizure by ensuring a safe environment.