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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The nurse is planning a staff education program about seizures. It would be correct for the nurse to characterize complex partial seizures as
- A. A seizure that may cause syncope lasting for 1 to 3 minutes.
- B. A seizure where the individual remains conscious throughout the episode.
- C. A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion.
- D. A brief jerking or stiffening of the extremities that may occur singly or in groups.
Correct Answer: B
Rationale: Complex partial seizures involve impaired consciousness, not full consciousness.
The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
- A. The client and their family members will arrange for rehabilitation.
- B. The rehabilitation plan should be implemented early in the client's treatment.
- C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities.
- D. Long-term care should be arranged, as the client can no longer perform self-care.
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 5 of 6
ED Triage Note
History And Physical
0912: Client was brought to the ED by her two college roommates 'because she was not acting right.' The roommate reports that she went to bed the night before reporting stiffness in her neck and a headache. She attributed it to being under pressure with final exams and having poor sleep the previous several days. The client apparently took non-prescribed lorazepam from another roommate to assist her with sleep. The roommate reported recently having influenza and is unsure if she became infected. It is reported that she declined the influenza vaccination when it was offered on campus. The roommate reports waking her with physical stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
For each physician order, click to specify the appropriate nursing intervention: Lumbar puncture
- A. Assess the client for an allergy to contrast dye
- B. Obtain laboratory work prior to the procedure
- C. Position the client flat before the procedure
- D. Monitor the client's temperature for efficacy
- E. Place an incontinence pad under the client for increased urinary output
- F. administer immediately after lumbar puncture
- G. establish a patent vascular access device
Correct Answer: B,F,G
Rationale: Obtaining labs (e.g., coagulation studies) ensures safety before lumbar puncture. Ketorolac may help reduce fever; monitoring temperature assesses its efficacy. Ceftriaxone is administered post-lumbar puncture to treat confirmed or suspected bacterial meningitis. Padding the bed prevents injury during potential seizures.
The following scenario applies to the next 1 items
The nurse cares for a 75-year-old client who arrives at the emergency department
Item 1 of 1
History And Physical
Vital Signs
1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress: Condition
- A. Transport the client for computed tomography (CT) scan
- B. Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
- C. Complex Migraine
- D. Severe Hypoglycemia
- E. Cerebral Vascular Accident
- F. Vital Signs
- G. Glasgow Coma Scale (GCS)
Correct Answer: A,B,E,F,G
Rationale: Symptoms (facial droop, hemiparesis, aphasia) indicate a stroke (CVA). CT scan and lab work are critical for stroke diagnosis and thrombolytic eligibility. GCS and vital signs monitor neurological and hemodynamic status in stroke.
A nurse is caring for a client on bed rest following a spinal cord injury. When positioning the client's feet, which position would prevent the client from developing foot drop?
- A. Supination
- B. Dorsiflexion
- C. Hyperextension
- D. Abduction
Correct Answer: B
Rationale: Dorsiflexion prevents foot drop by maintaining proper foot alignment.