Nokea
The nurse is caring for a client with a spinal cord injury. Which actions should the nurse take if the client develops autonomic dysreflexia?
- A. Notify the rapid response team.
- B. Assess the client's bladder for distention.
- C. Place the client in a modified Trendelenburg position.
- D. Prepare the client for an emergency lumbar puncture (LP).
- E. Obtain and monitor the client's blood pressure.
- F. Obtain a prescription for a vasopressor.
Correct Answer: A,B,E
Rationale: Notifying RRT, assessing bladder distention, and monitoring blood pressure address autonomic dysreflexia.
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The nurse is caring for a client who has an exacerbation of Bell's palsy and is experiencing paralysis of their eye. Which of the following actions should the nurse take?
- A. Tape an eye patch to the affected eyelid at all times.
- B. Instruct the client to keep both eyes closed.
- C. Assess the pupil's size and reactivity to light.
- D. Apply the prescribed ocular lubricant to the affected eye.
Correct Answer: D
Rationale: Ocular lubricant prevents corneal damage in Bell's palsy due to impaired eye closure.
The nurse is developing a plan of care for a client with advanced Alzheimer's disease. Which of the following should the nurse include?
- A. Assess the client's risk for falls
- B. Monitor the client for hyperorality
- C. Provide consistent caregivers
- D. Obtain a prescription for as-needed (PRN) diphenhydramine
- E. Foster a low-stimulation environment
- F. Offer limited choices
Correct Answer: A,B,C,E,F
Rationale: These interventions address safety, behavior, and comfort in advanced Alzheimer's disease.
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.
The nurse is caring for a client with an acute migraine headache. Which medication would the nurse anticipate a prescription for an acute migraine? Select all that apply.
- A. Ketorolac
- B. Nitroglycerin
- C. Topiramate
- D. Dexamethasone
- E. Hydromorphone
- F. Acetaminophen-caffeine
Correct Answer: A,F
Rationale: Ketorolac (an NSAID) and acetaminophen-caffeine are used for acute migraine relief. Nitroglycerin can worsen migraines, topiramate is for prevention, dexamethasone is not standard, and hydromorphone is not typically used for migraines.
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.