Nokea
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.
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The following scenario applies to the next 1 items
The emergency department (ED) nurse is caring for a 15-year-old who has sustained a sports-related injury
Item 1 of 1
Triage Note Triage Vital Signs
1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
The nurse assigned to the client reviews the triage note and plans care
The nurse anticipates taking which action? Prepare the client for a computed tomography (CT) scan of the head
- A. Prepare the client for a computed tomography (CT) scan of the head
- B. Perform a Glasgow Coma Scale (GCS)
- C. Encourage by mouth (PO) fluids
- D. Assess the client's pupils
- E. Prepare the client for a lumbar puncture (LP)
Correct Answer: A,A,B,A,B
Rationale: A CT scan is indicated to assess for brain injury in a client with head trauma and loss of consciousness. GCS assessment is critical to evaluate neurological status post-head injury. Encouraging PO fluids is inappropriate until a CT scan rules out increased intracranial pressure. Pupil assessment is essential to detect neurological changes post-head trauma. Lumbar puncture is not indicated unless specific conditions like meningitis are suspected.
The nurse is caring for a client prescribed tizanidine. The nurse understands that this medication has had a therapeutic effect when the client reports
- A. Increased ability to focus
- B. Decreased muscle spasms
- C. Improved short-term memory
- D. Sleeping without awakening at night
Correct Answer: B
Rationale: Tizanidine is a muscle relaxant used to treat spasticity. A therapeutic effect is indicated by decreased muscle spasms. Increased focus, improved memory, and better sleep are not primary effects of tizanidine.
The nurse is preparing to teach a client who was recently diagnosed with Meniere's disease. To help the client reduce the incidence of attacks, the nurse should recommend that the client do which of the following?
- A. Irrigate their ears with sterile water.
- B. Reduce dietary sodium intake.
- C. Do not use earbuds or headphones.
- D. Speak with limited inflections.
Correct Answer: B
Rationale: Reducing sodium intake helps manage fluid balance in Meniere's disease, reducing attack frequency.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 2 of 6
History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
The nurse recognizes that which of the following conditions may feature photophobia? Select all that apply.
- A. Migraine headache
- B. Guillain-Barré syndrome
- C. Meningitis
- D. Delirium
- E. Alzheimer's disease
- F. Parkinson's disease
Correct Answer: A,C
Rationale: Photophobia is a common symptom in migraine headaches and meningitis due to neurological sensitivity and inflammation, respectively. Guillain-Barré syndrome, delirium, Alzheimer's, and Parkinson's do not typically cause photophobia.
The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus?
- A. Rubor of the feet and ankles when the leg is in the dependent position
- B. Rapid, rhythmic muscle contractions
- C. Popping or clicking of the knee joint with movement
- D. Audible cracking and palpable grating with movement of the joints
Correct Answer: B
Rationale: Clonus is characterized by rapid, rhythmic muscle contractions, often seen in neurological disorders.