Nokea
The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected?
- A. Halitosis
- B. Chorea
- C. Hallucinations
- D. Hematemesis
- E. Weight loss
Correct Answer: B,E
Rationale: Chorea (involuntary movements) and weight loss are hallmark symptoms of Huntington's disease.
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The emergency department (ED) nurse triages a client with suspected bacterial meningitis. The nurse plans on assessing the client for Kernig's sign. The nurse understands that this sign is positive when the client?
- A. Reports pain when the knee is extended and the hip flexed.
- B. Has a stiff neck when the neck is flexed towards the chest.
- C. Forearm spasms when a blood pressure cuff is inflated on the upper arm.
- D. Reports pain in the calf when the foot is dorsiflexed.
Correct Answer: A
Rationale: Kernig's sign is positive when hip flexion with knee extension causes pain, indicating meningitis.
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.
The nurse is caring for a client who was prescribed lamotrigine. The nurse understands that this medication is intended to treat
- A. Acute spinal shock
- B. Epilepsy
- C. Parkinson's disease
- D. Multiple sclerosis
Correct Answer: B
Rationale: Lamotrigine is an anticonvulsant primarily used to treat epilepsy. It is not indicated for spinal shock, Parkinson's disease, or multiple sclerosis.
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 following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 4 of 6
ED Triage Note
History And Physical
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.
For each potential nursing intervention, click to specify whether the intervention is indicated or not indicated for the care of the client: A= Indicated, B= Not Indicated
- A. Keep the door to the client's room closed to maintain negative airflow
- B. Provide visitors with face shields upon entering the client's room
- C. Provide a quiet environment
- D. Perform frequent neurological assessments
- E. Obtain an order to start a peripheral vascular access device
- F. Prepare the client for an immediate electroencephalography (EEG)
Correct Answer: B,B,A,A,A,B
Rationale: Negative airflow is not typically required for bacterial meningitis unless airborne precautions are specified. Face shields are not standard for meningitis; droplet precautions are usually sufficient. A quiet environment reduces stimulation for a client with neurological symptoms. Frequent neurological assessments are critical for monitoring meningitis progression. IV access is necessary for administering antibiotics and fluids in suspected meningitis. EEG is not indicated unless seizures are suspected.