Nokea
The nurse is caring for a client who has an exacerbation of Bell's palsy and is experiencing paralysis of their eye. Which of the following actions should the nurse take?
- A. Tape an eye patch to the affected eyelid at all times.
- B. Instruct the client to keep both eyes closed.
- C. Assess the pupil's size and reactivity to light.
- D. Apply the prescribed ocular lubricant to the affected eye.
Correct Answer: D
Rationale: Ocular lubricant prevents corneal damage in Bell's palsy due to impaired eye closure.
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The nurse is assessing a client who is suspected of having myasthenia gravis. Which of the following would be an expected finding?
- A. Diplopia
- B. Butterfly rash
- C. Facial muscle weakness
- D. Shuffling gait
- E. Ptosis
Correct Answer: A,C,E
Rationale: Diplopia, facial muscle weakness, and ptosis are common in myasthenia gravis due to neuromuscular junction dysfunction.
The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
- A. Obtain an accurate weight
- B. Insert two peripheral vascular access devices
- C. Insert a nasogastric tube (NGT) immediately after alteplase infusion
- D. Obtain baseline laboratory work (CBC, CMP, aPTT, PT/INR) prior to infusion of alteplase
- E. Plan for admission to the medical-surgical floor
- F. Perform frequent neurological assessments
- G. Notify the physician if the systolic blood pressure is 185 mm Hg or greater
Correct Answer: A,A,B,A,B,A
Rationale: Accurate weight is critical for calculating the correct dose of alteplase for stroke treatment. Two peripheral IVs are needed for alteplase administration to ensure reliable access for the thrombolytic and other medications. NGT insertion is not immediately indicated post-alteplase unless swallowing difficulties are confirmed, to avoid complications. Baseline labs are essential to assess bleeding risk before administering thrombolytics like alteplase. Stroke patients receiving alteplase typically require ICU admission for close monitoring, not a medical-surgical floor. Frequent neurological assessments are critical post-alteplase to monitor for neurological changes or complications.
The emergency department (ED) nurse triages a client with suspected bacterial meningitis. The nurse plans on assessing the client for Kernig's sign. The nurse understands that this sign is positive when the client?
- A. Reports pain when the knee is extended and the hip flexed.
- B. Has a stiff neck when the neck is flexed towards the chest.
- C. Forearm spasms when a blood pressure cuff is inflated on the upper arm.
- D. Reports pain in the calf when the foot is dorsiflexed.
Correct Answer: A
Rationale: Kernig's sign is positive when hip flexion with knee extension causes pain, indicating meningitis.
The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?
- A. Atonic seizure
- B. Tonic-clonic seizure
- C. Absence seizure
- D. Complex partial seizure
Correct Answer: A
Rationale: Atonic seizures involve a sudden loss of muscle tone, often causing falls.
The nurse is evaluating a patient's response to peripheral pain. Which technique should the nurse use to perform this evaluation?
- A. Pressure on the patient's mid-back
- B. Sternal rub
- C. Squeezing the sternocleidomastoid muscle
- D. Pressing on the patient's nail bed
Correct Answer: D
Rationale: Nail bed pressure is a standard technique to assess peripheral pain response.