Nokea
The nurse is performing a physical assessment on a client. Which of the following findings would indicate a positive result for clonus?
- A. Rubor of the feet and ankles when the leg is in the dependent position
- B. Rapid, rhythmic muscle contractions
- C. Popping or clicking of the knee joint with movement
- D. Audible cracking and palpable grating with movement of the joints
Correct Answer: B
Rationale: Clonus is characterized by rapid, rhythmic muscle contractions, often seen in neurological disorders.
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The nurse is supervising a graduate nurse implement seizure precautions for a client with epilepsy. Which observation by the nurse requires follow-up?
- A. Pads the side rails of the bed
- B. Lowers the side rails while the client sleeps.
- C. Removes hard and sharp objects from the bed.
- D. Places the client in four point restraints to prevent injury.
- E. Places a fall risk bracelet on the client.
Correct Answer: B,D
Rationale: Lowering side rails and using restraints increase injury risk during seizures and require correction.
The following scenario applies to the next 1 items
The nurse cares for a 75-year-old client who arrives at the emergency department
Item 1 of 1
History And Physical
Vital Signs
1900: The client arrives with left facial droop, inability to move her left arm and leg, and expressive aphasia. According to the husband, they were out eating dinner, and the symptoms started suddenly, and she fell to the ground. The symptoms started 45 minutes prior to arrival at the ED. Past medical history includes atrial fibrillation, hypertension, diabetes mellitus, and hyperlipidemia.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two (2) actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress: Condition
- A. Transport the client for computed tomography (CT) scan
- B. Obtain laboratory work (PT, INR, aPTT, troponin, CBC, CMP, Capillary Blood glucose)
- C. Complex Migraine
- D. Severe Hypoglycemia
- E. Cerebral Vascular Accident
- F. Vital Signs
- G. Glasgow Coma Scale (GCS)
Correct Answer: A,B,E,F,G
Rationale: Symptoms (facial droop, hemiparesis, aphasia) indicate a stroke (CVA). CT scan and lab work are critical for stroke diagnosis and thrombolytic eligibility. GCS and vital signs monitor neurological and hemodynamic status in stroke.
The nurse is caring for a client scheduled for a lumbar puncture (LP). Which of the following clinical manifestations would require follow-up by the nurse before the LP?
- A. Nuchal rigidity
- B. Temperature 101° F (38.3° C)
- C. Petechial rash
- D. Restlessness
Correct Answer: A,B,C
Rationale: Nuchal rigidity, fever, and petechial rash suggest meningitis, which requires urgent evaluation before LP to avoid complications.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 2 of 6
History and Physical
1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus.
Physical Examination
Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia.
Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light.
Head and neck examination: Denies sinus pain and full cervical range of motion.
Integumentary: Skin warm to touch and pale pink in tone.
Cardiovascular: Peripheral pulses 2+ and no peripheral edema.
Respiratory: Clear lung sounds bilaterally.
Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention.
Psych: Anxious and in moderate distress. Cooperative.
Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air
The nurse recognizes that which of the following conditions may feature photophobia? Select all that apply.
- A. Migraine headache
- B. Guillain-Barré syndrome
- C. Meningitis
- D. Delirium
- E. Alzheimer's disease
- F. Parkinson's disease
Correct Answer: A,C
Rationale: Photophobia is a common symptom in migraine headaches and meningitis due to neurological sensitivity and inflammation, respectively. Guillain-Barré syndrome, delirium, Alzheimer's, and Parkinson's do not typically cause photophobia.
The nurse is performing a follow-up assessment on a client who was prescribed carbidopa/levodopa. Which assessment finding would indicate a therapeutic finding from this medication?
- A. Decrease in tremors
- B. Improvement in the excessive drooling
- C. Reduction in seizure activity
- D. Improvement in muscle spasticity
Correct Answer: A
Rationale: Carbidopa/levodopa is used for Parkinson's disease, and a decrease in tremors indicates therapeutic efficacy.