Nokea
The nurse is caring for a client receiving intravenous (IV) alteplase for a cerebrovascular accident (CVA). The nurse understands that this medication has reached its therapeutic effect when the client is assessed to have
- A. Increase in the Glasgow Coma Scale
- B. Unintelligible speech
- C. Bleeding at their gum line
- D. Increase in pulse and decrease in blood pressure
Correct Answer: A
Rationale: Alteplase is a thrombolytic used to dissolve clots in acute ischemic stroke, improving neurological function, as indicated by an increased Glasgow Coma Scale. Unintelligible speech, bleeding, and vital sign changes are not therapeutic effects.
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The nurse has received a prescription for a mannitol infusion. Which type of intravenous tubing should be used to administer mannitol?
- A. Microdrip
- B. Filtered
- C. Vented
- D. Non-vented
Correct Answer: B
Rationale: Mannitol is a hyperosmolar diuretic that can crystallize in IV tubing, potentially causing blockages. Filtered tubing is required to prevent crystals from entering the bloodstream, ensuring safe administration. Microdrip, vented, and non-vented tubing do not address this risk.
The nurse is caring for a client with an acute migraine headache. Which medication would the nurse anticipate a prescription for an acute migraine? Select all that apply.
- A. Ketorolac
- B. Nitroglycerin
- C. Topiramate
- D. Dexamethasone
- E. Hydromorphone
- F. Acetaminophen-caffeine
Correct Answer: A,F
Rationale: Ketorolac (an NSAID) and acetaminophen-caffeine are used for acute migraine relief. Nitroglycerin can worsen migraines, topiramate is for prevention, dexamethasone is not standard, and hydromorphone is not typically used for migraines.
The nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?
- A. Confusion
- B. Disorientation
- C. Agitation
- D. Delirium
- E. Hypervigilance
Correct Answer: A,B,C,D,E
Rationale: These findings (confusion, disorientation, agitation, delirium, hypervigilance) are all indicative of altered mental status, often seen in elderly patients with infections like pneumonia due to physiological stress or hypoxia.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 6 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
• Diagnostics Test Results
Head Computed Tomography (CT) scan
1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes.
• Nurses' Notes
1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.
The nurse makes a note in the nurses' notes and reviews the diagnostic test results. Complete the sentence below from the list of options. The client is most likely experiencing--------------------as evidenced by------------------and-----------------
- A. transient ischemic attack
- B. somatic anxiety symptoms
- C. ischemic stroke
- D. migraine headache
- E. photophobia
- F. throbbing headache
Correct Answer: D,E,F
Rationale: The client's presentation is most consistent with a migraine headache. Given the client's history of recurrent migraines, the persistent throbbing pain localized behind the left eye, nausea, photophobia, and phonophobia, the symptoms strongly align with a migraine rather than an alternative neurological or psychiatric condition.
While the client’s transient confusion and difficulty speaking raise concerns for a transient ischemic attack (TIA) or stroke, a TIA typically resolves within 30 to 60 minutes and does not persist beyond 24 hours. A TIA is highly unlikely since the client’s headache has been ongoing for 48 hours. Furthermore, ischemic strokes typically present with persistent focal neurological deficits, which are absent on the client's neurological exam.
Although the client has a documented history of generalized anxiety and panic disorder, panic attacks do not last for extended durations and generally resolve within minutes to an hour. Additionally, panic-related somatic symptoms typically include shortness of breath, dizziness, chest discomfort, and a sense of impending doom, rather than the prolonged headache, visual disturbances, and nausea seen in this case.
The nurse is caring for a client who presents to the emergency department with sudden-onset weakness on one side of the body and difficulty speaking. The nurse suspects the client may be experiencing a stroke. Which assessment finding would further support the possibility that the client is experiencing a stroke?
- A. Cardiac arrhythmia
- B. Orthostatic hypotension
- C. Anisocoria
- D. Hypoglycemia
Correct Answer: C
Rationale: Anisocoria (unequal pupils) can indicate stroke-related neurological changes.