Nokea
The nurse is caring for a client who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse?
- A. Administer prescribed carbamazepine
- B. Notify the rapid response team (RRT)
- C. Obtain a prescription for lorazepam
- D. Loosen any restrictive clothing
- E. Review the client's most recent phenytoin level
Correct Answer: B,C,D
Rationale: Status epilepticus is a medical emergency requiring immediate action. Notifying the RRT ensures rapid intervention, obtaining a lorazepam prescription is critical to stop seizures, and loosening restrictive clothing prevents injury and ensures airway patency.
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The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
- A. Cocaine intoxication
- B. Respiratory acidosis
- C. Tonic-clonic seizures
- D. Aggression
Correct Answer: B
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.
The nurse is caring for an elderly home health client experiencing a sudden onset of delirium. Which of the following should the home health nurse assess first?
- A. Drug intoxication
- B. Increased hearing loss
- C. Cancer metastases
- D. Congestive heart failure
Correct Answer: A
Rationale: Drug intoxication is a common and reversible cause of delirium in the elderly.
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 caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
- A. Abrupt onset
- B. Change in psychomotor activity
- C. Irreversible
- D. Progressively worsens
- E. Decreased attention and awareness
- F. Fluctuating level of consciousness
Correct Answer: A,B,E,F
Rationale: Delirium is characterized by abrupt onset, changes in psychomotor activity, decreased attention, and fluctuating consciousness. It is reversible, unlike dementia.
The nurse is caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider?
- A. Trazodone
- B. Modafinil
- C. Diazepam
- D. Fluoxetine
Correct Answer: B
Rationale: Modafinil is a wakefulness-promoting agent used to treat excessive daytime sleepiness in narcolepsy. Trazodone, diazepam, and fluoxetine are not indicated for narcolepsy.