Nokea
The nurse is caring for an elderly home health client experiencing a sudden onset of delirium. Which of the following should the home health nurse assess first?
- A. Drug intoxication
- B. Increased hearing loss
- C. Cancer metastases
- D. Congestive heart failure
Correct Answer: A
Rationale: Drug intoxication is a common and reversible cause of delirium in the elderly.
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The nurse is planning a staff education program about seizures. It would be correct for the nurse to characterize complex partial seizures as
- A. A seizure that may cause syncope lasting for 1 to 3 minutes.
- B. A seizure where the individual remains conscious throughout the episode.
- C. A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion.
- D. A brief jerking or stiffening of the extremities that may occur singly or in groups.
Correct Answer: B
Rationale: Complex partial seizures involve impaired consciousness, not full consciousness.
The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
- A. Cocaine intoxication
- B. Respiratory acidosis
- C. Tonic-clonic seizures
- D. Aggression
Correct Answer: B
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.
After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the:
- A. Abdomen
- B. Arms
- C. Legs
- D. Chest
Correct Answer: C
Rationale: L3 spinal cord injury affects lower extremity motor function, leading to leg paralysis.
The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
- A. The client can control the motorized wheelchair.
- B. The client states she wants to stand up with assistance.
- C. The client says she wants to move her toes.
- D. The client says she regained her bladder control.
Correct Answer: A
Rationale: Controlling a motorized wheelchair indicates improved upper body function, appropriate for C6-C7 injury.
The nurse is caring for a client receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.