Nokea
The nurse is evaluating a patient's response to peripheral pain. Which technique should the nurse use to perform this evaluation?
- A. Pressure on the patient's mid-back
- B. Sternal rub
- C. Squeezing the sternocleidomastoid muscle
- D. Pressing on the patient's nail bed
Correct Answer: D
Rationale: Nail bed pressure is a standard technique to assess peripheral pain response.
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The nurse is caring for a client who has been prescribed carbidopa-levodopa for Parkinson's disease. The nurse should instruct the client that this medication may cause Select all that apply.
- A. Urine to appear darker
- B. Hallucinations
- C. Dizziness upon standing
- D. Dry, non-productive cough
- E. Painful rash that spreads and blisters
Correct Answer: A,B,C
Rationale: Carbidopa-levodopa can cause darker urine (due to metabolism), hallucinations (a CNS side effect), and dizziness upon standing (orthostatic hypotension). Dry cough and rashes are not typical side effects.
The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition?
- A. Multiple Sclerosis
- B. Parkinson disease
- C. Schizophrenia
- D. Guillain-Barré syndrome
Correct Answer: B
Rationale: Ropinirole is a dopamine agonist used to treat Parkinson's disease by improving motor symptoms. It is not indicated for Multiple Sclerosis, Schizophrenia, or Guillain-Barré syndrome, which involve different pathophysiology and treatments.
The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?
- A. Periorbital ecchymosis
- B. Retroauricular or mastoid ecchymosis
- C. Temperature 100.9°F (38.3°C)
- D. Headache
Correct Answer: A,B
Rationale: Periorbital and retroauricular ecchymosis (raccoon eyes and Battle's sign) are hallmark signs of basilar skull fracture, requiring immediate follow-up.
The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.
The nurse is performing a medication reconciliation for a client taking prescribed phenytoin. Which medication should the nurse question with the physician while the client is taking phenytoin?
- A. Thiamine
- B. Prazosin
- C. Warfarin
- D. Acyclovir
Correct Answer: C
Rationale: Phenytoin induces liver enzymes, which can decrease warfarin's effectiveness, increasing the risk of clotting. Thiamine, prazosin, and acyclovir have no significant interactions with phenytoin.