Nokea
The nurse is developing a plan of care for a client with an impairment to the hypoglossal cranial nerve. Which of the following should the nurse include in the client's plan of care?
- A. Observe the client during meals
- B. Keep suction at the bedside
- C. Provide large print education materials
- D. Teach the client to scan the room
- E. Alternate the use of an eye patch
Correct Answer: A,B
Rationale: Hypoglossal nerve impairment affects tongue movement, increasing choking risk, necessitating meal observation and suction availability.
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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 1 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.
Which of the following assessment findings require immediate follow-up?
- A. Neurological assessment findings
- B. Pulse and temperature
- C. Gastrointestinal assessment findings
- D. Influenza vaccination status
- E. Daily smoking habit
- F. Blood pressure and pulse oximetry reading
Correct Answer: A,B
Rationale: Altered mental status, fever, and tachycardia suggest a serious condition like meningitis, requiring immediate follow-up.
The emergency department (ED) nurse cares for a client with a suspected cerebrovascular accident (CVA). Which actions should the nurse take?
- A. Perform a Glasgow coma scale (GCS)
- B. Assess the client's capillary blood glucose (CBG)
- C. Prepare the client for an immediate computed tomography (CT) scan of the brain
- D. Insert a nasogastric tube (NGT)
- E. Determine the onset of the symptoms or the last known well (LKW)
Correct Answer: A,B,C,E
Rationale: GCS, CBG, CT scan, and determining symptom onset are critical for stroke assessment and management.
A nurse is instructing a client about a newly prescribed medication, phenytoin. Which statements, if made by the client, indicate effective teaching?
- A. If my gums get irritated and large, I can stop this medication.
- B. I will need laboratory work to monitor the medication level.
- C. It is okay for me to increase this medication if I have a seizure.
- D. I should take this medication with low protein foods.
Correct Answer: B
Rationale: Phenytoin requires regular blood level monitoring to ensure therapeutic levels (10-20 mcg/mL). Stopping due to gum hyperplasia, increasing doses without medical advice, or taking with low-protein foods are incorrect.
A client is admitted with a possible diagnosis of Guillain-Barré syndrome. Which important question should the nurse include when taking this client's history?
- A. Do you experience frequent bruising?'
- B. Did you have a recent respiratory or gastrointestinal infection?'
- C. Have you been overseas during the past four months?'
- D. Has anybody in your family had Guillain-Barré syndrome?'
Correct Answer: B
Rationale: Recent infections are a common trigger for Guillain-Barré syndrome.
The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?
- A. Prepares to administer intravenous valproate.
- B. Place the client in a lateral position.
- C. Activates the rapid response team (RRT).
- D. Loosens any restrictive clothing.
Correct Answer: A
Rationale: Valproate is not a first-line treatment for status epilepticus; benzodiazepines like lorazepam are preferred.