Nokea
The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?
- A. Periorbital ecchymosis
- B. Retroauricular or mastoid ecchymosis
- C. Temperature 100.9°F (38.3°C)
- D. Headache
Correct Answer: A,B
Rationale: Periorbital and retroauricular ecchymosis (raccoon eyes and Battle's sign) are hallmark signs of basilar skull fracture, requiring immediate follow-up.
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The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 6 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
• Diagnostics Test Results
Head Computed Tomography (CT) scan
1739: No acute intracranial hemorrhage, mass effect, or midline shift identified. The ventricles and sulci are within normal limits. No evidence of acute ischemic changes.
• Nurses' Notes
1741: Client placed back in room following emergent CT scan of the head. The client is alert, fully oriented, cooperative, and slightly anxious. Reports 'throbbing' headache rated 7/10 on the Numerical Rating Scale. Endorses photophobia, requesting lights to be turned off. Glasgow coma scale is 15. Clear lung sounds bilaterally. Peripheral pulses 2+. Reports persistent nausea. Full range of motion in all extremities. A 20-gauge peripheral vascular access device was started in the left antecubital space.
The nurse makes a note in the nurses' notes and reviews the diagnostic test results. Complete the sentence below from the list of options. The client is most likely experiencing--------------------as evidenced by------------------and-----------------
- A. transient ischemic attack
- B. somatic anxiety symptoms
- C. ischemic stroke
- D. migraine headache
- E. photophobia
- F. throbbing headache
Correct Answer: D,E,F
Rationale: The client's presentation is most consistent with a migraine headache. Given the client's history of recurrent migraines, the persistent throbbing pain localized behind the left eye, nausea, photophobia, and phonophobia, the symptoms strongly align with a migraine rather than an alternative neurological or psychiatric condition.
While the client’s transient confusion and difficulty speaking raise concerns for a transient ischemic attack (TIA) or stroke, a TIA typically resolves within 30 to 60 minutes and does not persist beyond 24 hours. A TIA is highly unlikely since the client’s headache has been ongoing for 48 hours. Furthermore, ischemic strokes typically present with persistent focal neurological deficits, which are absent on the client's neurological exam.
Although the client has a documented history of generalized anxiety and panic disorder, panic attacks do not last for extended durations and generally resolve within minutes to an hour. Additionally, panic-related somatic symptoms typically include shortness of breath, dizziness, chest discomfort, and a sense of impending doom, rather than the prolonged headache, visual disturbances, and nausea seen in this case.
The nurse is caring for a client with Bell's palsy. Which of the following prescriptions should the nurse anticipate administering to the client?
- A. Modafinil
- B. Prednisone
- C. Doxycycline
- D. Acyclovir
- E. Sumatriptan
Correct Answer: B,D
Rationale: Prednisone reduces inflammation, and acyclovir treats potential viral causes in Bell's palsy.
The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.
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 nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.