Nokea
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.
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Which statement below relating to pain and pain perception is accurate?
- A. Allodynia is the pathophysiological absence of pain when a painful stimulus is applied.
- B. Scientific evidence does not support the presence of pain during neonatal circumcision.
- C. Hyperalgesia is the opposite of hyperpathia, both of which are abnormal pain responses.
- D. The perception of pain and its impact on clients vary greatly among individuals.
Correct Answer: D
Rationale: Pain perception varies widely due to individual physiological and psychological factors.
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 assessing a client with Guillain-Barré syndrome. Which of the following would be an expected finding?
- A. Hyperreflexia
- B. Perseveration
- C. Dystonia
- D. Paresthesia
Correct Answer: D
Rationale: Paresthesia (tingling/numbness) is common in Guillain-Barré syndrome due to peripheral nerve demyelination.
A 28-year-old woman presents to the trauma bay after being shot in the upper back. She can move the left side of her body but cannot move the right. However, she cannot feel any pain in her left. The nurse knows these symptoms suggest which type of spinal cord injury?
- A. Incomplete spinal cord injury, central cord syndrome
- B. Incomplete spinal cord injury, Brown-Sequard syndrome
- C. Complete spinal cord injury, paraplegia
- D. Incomplete spinal cord injury, anterior cord syndrome
Correct Answer: B
Rationale: Brown-Sequard syndrome involves ipsilateral motor loss and contralateral sensory loss.
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.