Nokea
The nurse is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
- A. Abrupt onset
- B. Change in psychomotor activity
- C. Irreversible
- D. Progressively worsens
- E. Decreased attention and awareness
- F. Fluctuating level of consciousness
Correct Answer: A,B,E,F
Rationale: Delirium is characterized by abrupt onset, changes in psychomotor activity, decreased attention, and fluctuating consciousness. It is reversible, unlike dementia.
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The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for VPA toxicity
- D. Document the result as within normal limits
Correct Answer: A
Rationale: A VPA level of 40 mcg/mL is below the therapeutic range (50-125 mcg/mL), suggesting possible non-adherence to the prescribed regimen. Skipping a dose is inappropriate, toxicity is unlikely with a low level, and the result is not within normal limits.
The nurse is caring for a client with newly prescribed sumatriptan. The nurse understands that this medication is intended to treat which condition?
- A. Peripheral artery disease
- B. Accelerated hypertension
- C. Migraine headache
- D. Angina
Correct Answer: C
Rationale: Sumatriptan is a triptan specifically used to treat migraine headaches by constricting blood vessels and reducing inflammation. It is not used for peripheral artery disease, hypertension, or angina.
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.
Of the following, which conditions would the nurse recognize as potential sources of neuropathic pain?
- A. Spinal tumor
- B. Arthritic joint
- C. Muscle strain
- D. Shingles
- E. Kidney stones
Correct Answer: A,D
Rationale: Spinal tumors and shingles cause neuropathic pain due to nerve involvement.
In a client with spinal cord injury, the nurse understands which of the following symptoms are indicative of autonomic dysreflexia?
- A. Hypotension
- B. Sudden headache
- C. Flushed face
- D. Nasal congestion
- E. Profuse sweating above the level of the injury
Correct Answer: B,C,D,E
Rationale: Autonomic dysreflexia causes headache, flushing, nasal congestion, and sweating above the injury level due to sympathetic overactivity.