Nokea
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.
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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 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 caring for a client with narcolepsy. The nurse anticipates which prescription from the primary healthcare provider?
- A. Trazodone
- B. Modafinil
- C. Diazepam
- D. Fluoxetine
Correct Answer: B
Rationale: Modafinil is a wakefulness-promoting agent used to treat excessive daytime sleepiness in narcolepsy. Trazodone, diazepam, and fluoxetine are not indicated for narcolepsy.
The nurse is evaluating the progress of a completely paraplegic female client with a C6-C7 spinal cord injury. Which indicator signifies that the client is improving in physical therapy?
- A. The client can control the motorized wheelchair.
- B. The client states she wants to stand up with assistance.
- C. The client says she wants to move her toes.
- D. The client says she regained her bladder control.
Correct Answer: A
Rationale: Controlling a motorized wheelchair indicates improved upper body function, appropriate for C6-C7 injury.
The nurse is performing medication reconciliation for a client with Parkinson's disease. Which medication should the nurse question with the primary healthcare provider (PHCP)?
- A. Haloperidol
- B. Levodopa-carbidopa
- C. Pramipexole
- D. Ropinirole
Correct Answer: A
Rationale: Haloperidol is a typical antipsychotic that blocks dopamine receptors, which can worsen Parkinson's disease symptoms by counteracting the dopamine-enhancing effects of medications like levodopa-carbidopa, pramipexole, and ropinirole, which are used to manage Parkinson's disease.