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The nurse is caring for a client hospitalized with a severe exacerbation of myasthenia gravis. When administering medications to this client, what is a priority nursing action?
- A. Assess client's reaction to new medication schedule.
- B. Administer medications at exact intervals ordered.
- C. Document medication given and dose.
- D. Give client plenty of fluids with medications.
Correct Answer: B
Rationale: The nurse must administer medications at the exact intervals ordered to maintain therapeutic blood levels and prevent symptoms from returning. Assessing the client's reaction, documenting medication and dose, and giving the client plenty of fluids are not the priority nursing action for this client.
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A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?
- A. Dextrose 5% in water (D5W)
- B. Half-normal saline (0.45% NSS)
- C. One-third normal saline (0.33% NSS)
- D. Lactated Ringer's
Correct Answer: D
Rationale: With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
A client falls to the floor in a generalized seizure with tonic-clonic movements. Which is the first action taken by the nurse?
- A. Insert an airway or bite block.
- B. Manually restrain the extremities.
- C. Turn client to side-lying position.
- D. Monitor vital signs.
Correct Answer: C
Rationale: When a client begins to convulse, the highest priority is to maintain airway. This can best be accomplished by turning client to side-lying position, which allows saliva and emesis to drain from the mouth. Turning the client also allows the tongue to fall forward opening the airway. More damage can occur if a bite block is inserted after the seizure has begun. Manually restraining extremities is not recommended. Attempting to take blood pressure is not recommended and pulse rate and respirations during the event will not be beneficial. Monitor vital signs during the postictal phase.
The nurse is caring for a client who has a generalized seizure. Which nursing assessment is a priority for detailing the event?
- A. Seizure began at 1300 hours.
- B. The client cried out before the seizure began.
- C. Seizure was 1 minute in duration including tonic-clonic activity.
- D. Sleeping quietly after the seizure
Correct Answer: C
Rationale: Describing the length and the progression of the seizure is a priority nursing responsibility. During this time, the client will experience respiratory spasms, and the skin will appear cyanotic, indicating a period of lack of tissue oxygenation. Noting when the seizure began and presence of an aura are also valuable pieces of information. Postictal behavior should be documented along with vital signs, oxygen saturation, and assessment of tongue and oral cavity.
Which client goal, established by the nurse, is most important as the nurse plans care for a seizure client in the home setting?
- A. The client will take the seizure medication at the same time daily.
- B. The client will remain free of injury if a seizure does occur.
- C. The client will verbalize an understanding of feelings that preempt seizure activity.
- D. The client will post emergency numbers on the refrigerator for ease of obtaining.
Correct Answer: B
Rationale: All of the goals are appropriate, but the most important goal is the long-term goal to remain free of injury if a seizure occurs. Nursing interventions associated can include notifying someone of not feeling well, lowering self to a safe position, protecting head, turning on a side, etc. Also, the client may be at a risk for injury because, once a seizure begins, the client cannot implement self-protective behaviors. An established plan is important in the care of a seizure client. The other options are acceptable goals for nursing care.
A client is receiving baclofen for management of symptoms associated with multiple sclerosis. To evaluate the effectiveness of this medication, what does the nurse assess?
- A. Sleep pattern
- B. Mood and affect
- C. Appetite
- D. Muscle spasms
Correct Answer: D
Rationale: Baclofen is a drug used to manage symptoms of muscle spasticity and rigidity in clients diagnosed with neuromuscular disorders. Because of the effects on the CNS, initially, baclofen may cause drowsiness, but sleep is not the intended goal for this therapy. Mood and appetite are not a factor in the administration of this drug.