Nokea
The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?
- A. Atonic seizure
- B. Tonic-clonic seizure
- C. Absence seizure
- D. Complex partial seizure
Correct Answer: A
Rationale: Atonic seizures involve a sudden loss of muscle tone, often causing falls.
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The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
- A. Obtain an accurate weight
- B. Insert two peripheral vascular access devices
- C. Insert a nasogastric tube (NGT) immediately after alteplase infusion
- D. Obtain baseline laboratory work (CBC, CMP, aPTT, PT/INR) prior to infusion of alteplase
- E. Plan for admission to the medical-surgical floor
- F. Perform frequent neurological assessments
- G. Notify the physician if the systolic blood pressure is 185 mm Hg or greater
Correct Answer: A,A,B,A,B,A
Rationale: Accurate weight is critical for calculating the correct dose of alteplase for stroke treatment. Two peripheral IVs are needed for alteplase administration to ensure reliable access for the thrombolytic and other medications. NGT insertion is not immediately indicated post-alteplase unless swallowing difficulties are confirmed, to avoid complications. Baseline labs are essential to assess bleeding risk before administering thrombolytics like alteplase. Stroke patients receiving alteplase typically require ICU admission for close monitoring, not a medical-surgical floor. Frequent neurological assessments are critical post-alteplase to monitor for neurological changes or complications.
The nurse has received a prescription for a mannitol infusion. Which type of intravenous tubing should be used to administer mannitol?
- A. Microdrip
- B. Filtered
- C. Vented
- D. Non-vented
Correct Answer: B
Rationale: Mannitol is a hyperosmolar diuretic that can crystallize in IV tubing, potentially causing blockages. Filtered tubing is required to prevent crystals from entering the bloodstream, ensuring safe administration. Microdrip, vented, and non-vented tubing do not address this risk.
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 following scenario applies to the next 1 items
The outpatient clinic nurse cares for a 40-year-old female client.
Item 1 of 1
Nurses' Notes
1450: Client reports to the clinic with her daughter because of various concerning symptoms that started about eight months ago. The client's daughter has noticed that her mother has become increasingly clumsy and uncoordinated. She reports that she is tripping over her own feet, which has caused her to fall twice. The client's daughter also reports becoming emotionally labile for 'no apparent reason.' The client reports that she gets 'spells of double vision that lasts for a few days' that seem to worsen with the heat. The client's daughter is concerned because her mother is not the 'get up and go' type of woman she used to be. The client does endorse generalized fatigue that worsens as the day progresses. In fact, she states
She goes to bed early because she gets so tired by 6 pm. The client says that two weeks ago, her vision doubled so much that she purchased an eye patch at the drugstore, which did help. Her daughter reports checking on her mother; her language was garbled and unrecognizable. She was almost ready to take her to the ED because she thought she was having a stroke. Finally, the client provided documentation from two urgent care visits in the past six months because of urinary tract infections. The client indicates she has had urinary problems dealing with urgency. She states that she has no pain, and in fact, she has difficulty determining if she has a UTI because she has decreased sensation in her pelvic region, which she cannot explain. On assessment, the client's breathing is unlabored, and breath sounds are clear bilaterally. Skin warm to touch with no tenting; bruising noted on the client's shins; pulses 2+ and regular. Capillary refill is 3 seconds. The client is alert and oriented to person, place, and situation. She currently takes no medications and has a medical history of uterine fibroids.
For each client finding below, click to specify if the finding is consistent with the disease process of Parkinson's disease, myasthenia gravis, or multiple sclerosis:
- A. Diplopia
- B. Emotional lability
- C. generalized fatigue
- D. Muscle incoordination
- E. diminished response to pain
- F. heat sensitivity
- G. urinary urgency
Correct Answer: B,C,A,C
Rationale: Diplopia is common in myasthenia gravis (due to ocular muscle weakness) and multiple sclerosis (due to optic nerve involvement). Emotional lability is a hallmark of multiple sclerosis due to demyelination affecting emotional regulation. Fatigue is common in myasthenia gravis (muscle fatigability) and multiple sclerosis (due to neurological dysfunction).
The nurse is caring for a client with a migraine headache. Which assessment findings should the nurse expect?
- A. Unilateral frontotemporal pain
- B. Nausea
- C. Photophobia
- D. Fever
- E. Nuchal rigidity
- F. Vomiting
Correct Answer: A,B,C,F
Rationale: Migraine headaches typically present with unilateral pain, nausea, photophobia, and vomiting.