Nokea
The nurse is caring for a client who has been prescribed carbidopa-levodopa for Parkinson's disease. The nurse should instruct the client that this medication may cause Select all that apply.
- A. Urine to appear darker
- B. Hallucinations
- C. Dizziness upon standing
- D. Dry, non-productive cough
- E. Painful rash that spreads and blisters
Correct Answer: A,B,C
Rationale: Carbidopa-levodopa can cause darker urine (due to metabolism), hallucinations (a CNS side effect), and dizziness upon standing (orthostatic hypotension). Dry cough and rashes are not typical side effects.
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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 caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?
- A. Active range of motion in both arms
- B. Scant drainage on the dressing
- C. Difficulty swallowing liquids
- D. Soreness at the operative site
Correct Answer: C
Rationale: Difficulty swallowing (dysphagia) post-cervical spinal surgery could indicate complications like nerve damage or swelling, requiring immediate follow-up.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 1 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
The nurse is assessing the client with a persistent headache. Which two (2) findings from the client's history and physical examination are most concerning and require immediate intervention?
- A. Headache described as throbbing and located behind the left eye
- B. Visual disturbances, including flashes of light and blurred vision
- C. Confusion and difficulty speaking
- D. Persistent nausea despite normoactive bowel sounds
- E. Use of escitalopram and buspirone for generalized anxiety disorder
- F. Right arm weakness
Correct Answer: C,F
Rationale: Confusion, difficulty speaking, and right arm weakness suggest a possible stroke or other serious neurological condition, requiring immediate intervention. Throbbing headache, visual disturbances, nausea, and medication use are less urgent.
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 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 2 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 client finding below, click to specify if the finding is consistent with the disease process of benzodiazepine toxicity, bacterial meningitis, or influenza:
- A. Altered mental status
- B. Fever
- C. Petechial rash
- D. Altered speech pattern
- E. Neck stiffness
Correct Answer: A,B,C,B,A,B
Rationale: Altered mental status is common in benzodiazepine toxicity (sedation) and bacterial meningitis (infection-related). Fever is typical in bacterial meningitis and influenza. Petechial rash is a hallmark of bacterial meningitis, especially meningococcal. Altered speech can occur in benzodiazepine toxicity (slurred speech) and meningitis (neurological impairment). Neck stiffness is a classic sign of bacterial meningitis.