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The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Drowsiness
- C. Photophobia
- D. Shuffling gait
- E. Dysphagia
- F. Vomiting
Correct Answer: A,C,F
Rationale: Unilateral pain, photophobia, and vomiting are typical migraine symptoms.
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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.
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 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 nurse is caring for an 82-year-old male client admitted to the hospital for pneumonia. Which of the following findings may indicate a change in mental status?
- A. Confusion
- B. Disorientation
- C. Agitation
- D. Delirium
- E. Hypervigilance
Correct Answer: A,B,C,D,E
Rationale: These findings (confusion, disorientation, agitation, delirium, hypervigilance) are all indicative of altered mental status, often seen in elderly patients with infections like pneumonia due to physiological stress or hypoxia.
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.