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The nurse is caring for a patient with Parkinson's disease who is admitted to the hospital for treatment of an acute infection. Which of the following nursing interventions will be included in the plan of care? (Select all that apply.)
- A. Use an elevated toilet seat.
- B. Cut patient's food into small pieces.
- C. Provide high protein foods at each meal.
- D. Place an arm chair at the patient's bedside.
- E. Observe for sudden exacerbation of symptoms.
Correct Answer: A,B,D
Rationale: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations.
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The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. Which of the following actions is priority for the nurse to take initially?
- A. Assess the patient for a possible head injury.
- B. Give the scheduled dose of divalproex
- C. Document the timing and description of the seizure.
- D. Notify the patient's health care provider about the seizure.
Correct Answer: A
Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure drugs also are appropriate actions, but the initial action should be assessment for injury.
The nurse is caring for a patient with myasthenia gravis who has had a thymectomy and receives the usual dose of pyridostigmine. An hour later, the patient has nausea and severe abdominal cramps. Which of the following actions should the nurse take first?
- A. Auscultate the patient's bowel sounds.
- B. Notify the patient's health care provider.
- C. Administer the prescribed PRN antiemetic drug.
- D. Give the scheduled dose of prednisone.
Correct Answer: B
Rationale: The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.
The nurse is caring for a patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder. Which of the following actions should the nurse plan to take?
- A. Teach the patient how to perform self-catheterization
- B. Decrease the patient's fluid intake in the evening
- C. Suggest the use of incontinence briefs for nighttime use only
- D. Assist the patient to the commode every 2 hours during the day.
Correct Answer: A
Rationale: Bladder control is a major problem for many patients with MS. Although anticholinergics may be beneficial for some patients to decrease spasticity, other patients may need to be taught self-catheterization. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
The nurse is caring for a patient with multiple sclerosis (MS) who is to begin treatment with glatiramer acetate. Which of the following information should the nurse include in patient teaching?
- A. Recommendation to drink at least 3-4 L of water daily
- B. Need to avoid driving or operating heavy machinery
- C. How to draw up and administer injections of the medication
- D. Use of contraceptive methods other than oral contraceptives
Correct Answer: C
Rationale: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.
The nurse is preparing to admit a patient who has been treated for status epilepticus in the emergency department. Which of the following equipment should the nurse have available in the room? (Select all that apply.)
- A. Side rail pads
- B. Tongue blade
- C. Oxygen mask
- D. Suction tubing
- E. Nasogastric tube
Correct Answer: A,C,D
Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades during a seizure is contraindicated.