Nokea
The nurse is planning a staff education program about seizures. It would be correct for the nurse to characterize complex partial seizures as
- A. A seizure that may cause syncope lasting for 1 to 3 minutes.
- B. A seizure where the individual remains conscious throughout the episode.
- C. A sudden loss of muscle tone, lasting for seconds, followed by postictal confusion.
- D. A brief jerking or stiffening of the extremities that may occur singly or in groups.
Correct Answer: B
Rationale: Complex partial seizures involve impaired consciousness, not full consciousness.
You may also like to solve these questions
The nurse is caring for a client experiencing autonomic dysreflexia. What action should the nurse perform first?
- A. Administer sublingual nitroglycerin.
- B. Elevate the head of the bed.
- C. Obtain a residual volume reading with a bladder scan.
- D. Perform a digital examination to assess for the presence of stool.
Correct Answer: B
Rationale: Elevating the head of the bed reduces blood pressure in autonomic dysreflexia.
The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. If I experience double-vision, I should put an eye patch on both eyes for a few hours.
- B. Planning my activities should help manage the fatigue.
- C. I should plan to take a hot bath for my muscle spasms.
- D. This disease may cause me to have an increased sensitivity to pain.
Correct Answer: B
Rationale: Planning activities helps manage fatigue, a common symptom in multiple sclerosis. Hot baths can worsen symptoms, and eye patches are used for one eye, not both.
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.
The nurse has administered the first dose of prescribed rivastigmine to a client with Alzheimer's disease. Which clinical data is necessary to monitor while this client takes this medication?
- A. Glucose
- B. Weight
- C. Creatinine
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: Rivastigmine, a cholinesterase inhibitor, can cause gastrointestinal side effects such as nausea, vomiting, and weight loss. Monitoring weight is essential to assess for significant weight loss, which can impact the client's health. Glucose, creatinine, and hemoglobin/hematocrit are not typically affected by rivastigmine.
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.