Nokea
The nurse is caring for a client with a concussion. Which assessment finding indicates that the client is experiencing a complication?
- A. Reports of a persistent headache
- B. Glasgow Coma Scale 13
- C. Heart rate 56
- D. Drowsiness
Correct Answer: C
Rationale: Bradycardia (heart rate 56) suggests increased intracranial pressure, a concussion complication.
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The nurse is caring for a client who is paraplegic secondary to a spinal cord injury. While planning this client's discharge, which would be most appropriate to include in the client's plan of care?
- A. The client and their family members will arrange for rehabilitation.
- B. The rehabilitation plan should be implemented early in the client's treatment.
- C. The client should plan for minimal and short-term rehabilitation, as they will return to their former activities.
- D. Long-term care should be arranged, as the client can no longer perform self-care.
Correct Answer: B
Rationale: Early rehabilitation is critical for optimizing recovery and adaptation in spinal cord injury patients.
The nurse is caring for a client with an acute exacerbation of Bell's palsy. The nurse anticipates that the physician will prescribe which medications? Select all that apply.
- A. Prednisone
- B. Donepezil
- C. Pyridostigmine
- D. Valacyclovir
- E. Topiramate
Correct Answer: A,D
Rationale: Prednisone (a corticosteroid) reduces inflammation, and valacyclovir (an antiviral) addresses possible viral causes in Bell's palsy. Donepezil, pyridostigmine, and topiramate are not indicated.
The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
- A. Administer sublingual nitroglycerin.
- B. Elevate the head of the bed.
- C. Obtain a residual volume reading with a bladder scan.
- D. Perform a digital examination to assess for the presence of stool.
Correct Answer: B
Rationale: Elevating the head of the bed reduces blood pressure in autonomic dysreflexia.
The following scenario applies to the next 1 items
The nurse in the emergency department is caring for a 22-year-old female.
Item 1 of 1
History And Physical Orders
1114: A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation.
For each physician order, click to specify the appropriate nursing intervention: Magnetic Resonance Imaging (MRI) of the brain
- A. Ensure the client has a negative pregnancy test prior to the exam
- B. Assess if the client has claustrophobia prior to the exam
- C. Have the client nothing by mouth (NPO) eight hours prior to the exam
- D. Monitor the client's lung sounds for pulmonary edema
- E. Establish continuous cardiac monitoring during the infusion
- F. Insert an indwelling urinary catheter to monitor intake and output
- G. Position the client side-lying with their knees to their chest
Correct Answer: A,B,E
Rationale: A negative pregnancy test is essential for female patients of childbearing age to avoid radiation risks to a fetus. Assessing for claustrophobia ensures patient comfort and safety during the MRI. Assessing for IV contrast dye allergy is necessary if contrast is used. Phenytoin can cause cardiac arrhythmias, so continuous cardiac monitoring is critical during infusion to detect and manage any adverse effects promptly. An EEG involves placing electrodes on the scalp, and instructing the client on how to remove adhesive post-test ensures proper care and comfort.
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.