Nokea
The nurse is reviewing laboratory data for a client with epilepsy taking prescribed valproic acid (VPA). The client's VPA level is 40 mcg/mL (50-125 mcg/mL). Based on the laboratory data, the nurse should
- A. Evaluate the client for non-adherence
- B. Instruct the client to skip the next scheduled dose
- C. Assess the client for VPA toxicity
- D. Document the result as within normal limits
Correct Answer: A
Rationale: A VPA level of 40 mcg/mL is below the therapeutic range (50-125 mcg/mL), suggesting possible non-adherence to the prescribed regimen. Skipping a dose is inappropriate, toxicity is unlikely with a low level, and the result is not within normal limits.
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The nurse has received a prescription for midazolam. Which of the following client findings requires follow-up with the physician prior to administering this medication?
- A. Cocaine intoxication
- B. Respiratory acidosis
- C. Tonic-clonic seizures
- D. Aggression
Correct Answer: B
Rationale: Midazolam, a benzodiazepine, can cause respiratory depression, which is dangerous in clients with respiratory acidosis. Tonic-clonic seizures are an indication for midazolam, while cocaine intoxication and aggression are less directly contraindicated.
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 is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
- A. Abrupt onset
- B. Change in psychomotor activity
- C. Irreversible
- D. Progressively worsens
- E. Decreased attention and awareness
- F. Fluctuating level of consciousness
Correct Answer: A,B,E,F
Rationale: Delirium is characterized by abrupt onset, changes in psychomotor activity, decreased attention, and fluctuating consciousness. It is reversible, unlike dementia.
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 receiving prescribed sumatriptan. Which client report would indicate that the client is experiencing an adverse response?
- A. Nervousness
- B. Warm sensation
- C. Angina
- D. Tingling sensation
Correct Answer: C
Rationale: Sumatriptan, a triptan used for migraines, can cause coronary vasospasm, leading to angina (chest pain), a serious adverse effect requiring immediate attention. Nervousness, warm sensation, and tingling are common, less severe side effects.