Nokea
The nurse is caring for a client who presents to the emergency department with sudden-onset weakness on one side of the body and difficulty speaking. The nurse suspects the client may be experiencing a stroke. Which assessment finding would further support the possibility that the client is experiencing a stroke?
- A. Cardiac arrhythmia
- B. Orthostatic hypotension
- C. Anisocoria
- D. Hypoglycemia
Correct Answer: C
Rationale: Anisocoria (unequal pupils) can indicate stroke-related neurological changes.
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The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 6 of 6
ED Triage Note
History And Physical
Physician Orders
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.
Click to highlight the findings below that indicate a worsening of the client's status: The client is lethargic and makes no purposeful movements. Does not respond to physical stimuli. Glasgow coma scale 10. Peripheral pulses 2+. The client's skin is pale and dry. Petechial rash on the torso. Vital signs: T 100.4° F (38° C), P 101, RR 12, BP 117/88, pulse oximetry reading 95%.
- A. Lethargic
- B. no purposeful movements
- C. does not respond to physical stimuli
- D. Glasgow coma scale 10
- E. petechial rash on the torso
Correct Answer: A,B,C,D,E
Rationale: These findings indicate worsening neurological status and possible progression of meningitis.
The primary healthcare provider (PHCP) is preparing to intubate a client. The PHCP prescribes succinylcholine. The nurse understands that this medication is intended to
- A. Sedate the client during the procedure
- B. Decrease oral and airway secretions
- C. Increase heart rate in case of a vagal response
- D. Cause skeletal muscle paralysis
Correct Answer: D
Rationale: Succinylcholine is a depolarizing neuromuscular blocker used to cause skeletal muscle paralysis, facilitating intubation. It does not sedate, reduce secretions, or increase heart rate.
The nurse is caring for a client eight hours postoperative following spinal surgery. Which action is essential for the nurse to take?
- A. Assess the client's pain while they receive patient-controlled analgesia (PCA)
- B. Log roll the client when turning the client from side to side
- C. Assist the client with ambulation to the bathroom
- D. Place pillows under the thighs of each leg when the client is supine
Correct Answer: B
Rationale: Log rolling maintains spinal alignment, preventing injury post-spinal surgery.
The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity?
- A. REM sleep
- B. Circadian rhythm
- C. Diurnal rhythm
- D. Nocturnal activity
Correct Answer: B
Rationale: Circadian rhythm refers to the body's 24-hour cycle regulating sleep and wakefulness.
The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition?
- A. Multiple Sclerosis
- B. Parkinson disease
- C. Schizophrenia
- D. Guillain-Barré syndrome
Correct Answer: B
Rationale: Ropinirole is a dopamine agonist used to treat Parkinson's disease by improving motor symptoms. It is not indicated for Multiple Sclerosis, Schizophrenia, or Guillain-Barré syndrome, which involve different pathophysiology and treatments.