Nokea
The nurse is reviewing the medication list of the client with Meniere's disease. Which medication was likely prescribed for treating the client's vertigo?
- A. Meclizine
- B. Megestrol
- C. Meropenem
- D. Metoprolol
Correct Answer: A
Rationale: The anticholinergic and antihistamine properties of meclizine (Antivert) treat the symptom of vertigo. Megestrol, meropenem, and metoprolol treat unrelated conditions.
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A stroke victim regains consciousness three days after admission. She has right-sided hemiparesis and hemiplegia and also has expressive aphasia. She becomes upset when she is unable to say simple words. The best approach for the nurse is to do which of the following?
- A. Stay with her and give her time and encouragement in attempting to speak.
- B. Say, 'I'm sure you want a glass of water. I'll get it for you.'
- C. Say, 'Don't get upset. You rest now and I'll come back later and try to talk to you then.'
- D. Encourage her attempts and say, 'Don't worry, it will get easier every day.'
Correct Answer: A
Rationale: Staying with the client and offering encouragement supports her attempts to speak, fostering communication and emotional support.
The client with glaucoma is prescribed pilocarpine hydrochloride 1% eye drops to both eyes four times per day. The nurse knows that this medication has which expected action?
- A. Increases the outflow of aqueous humor
- B. Improves vision in dimly lit environments
- C. Increases production of aqueous humor
- D. Increases ability of both pupils to dilate
Correct Answer: A
Rationale: Pilocarpine hydrochloride is a cholinergic agent used to treat glaucoma. It causes miosis (pupillary constriction), which then increases the angle of the channel in the anterior chamber of the eye. This improves the outflow of aqueous humor. It does not improve vision in dim light, increase aqueous humor production, or cause pupil dilation.
The nurse is assessing the client's cranial nerves. Which assessment data indicate cranial nerve I is intact?
- A. The client can identify cold and hot on the face.
- B. The client does not have any tongue tremor.
- C. The client has no ptosis of the eyelids.
- D. The client is able to identify a peppermint smell.
Correct Answer: D
Rationale: Cranial nerve I (olfactory) is assessed by identifying smells like peppermint. Temperature sensation (trigeminal), tongue movement (hypoglossal), and ptosis (oculomotor) involve other nerves.
A teenager is admitted following a seizure. The next day, the nurse goes into his room and finds him lying on the floor starting to have a seizure. What action should the nurse take at this time?
- A. Carefully observe the seizure and gently restrain him
- B. Attempt to put an airway in his mouth so he does not swallow his tongue, and observe the type and duration of the seizure
- C. Place something soft under his head, carefully observe the seizure, and protect him from injury
- D. Shout for help so that someone can help you move him away from the furniture
Correct Answer: C
Rationale: Placing something soft under the head and observing the seizure while protecting from injury ensures safety. Restraining or inserting an airway is not recommended, and the scenario does not indicate furniture-related danger.
The emergency department nurse is assessing a client who has a needle in the sclera of the right eyeball just below the iris. Which should the nurse implement first?
- A. Remove the needle with tweezers.
- B. Notify an ophthalmologist to care for the client.
- C. Stabilize the right eye and place a patch over the left eye.
- D. Irrigate the right eye to wash the needle out of the eye.
Correct Answer: C
Rationale: Stabilizing the eye and patching the unaffected eye prevents movement and further damage until surgical removal. Removing the needle, notifying later, or irrigating risks harm.