Nokea
The nurse who is caring for a post-stroke client suddenly notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse?
- A. Reduce environmental stimuli.
- B. Reassess after ten minutes.
- C. Check the client's blood pressure.
- D. Notify the physician.
Correct Answer: D
Rationale: A fixed and dilated pupil suggests increased intracranial pressure, requiring immediate physician notification.
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The following scenario applies to the next 1 items
A client arrives at the clinic with his daughter, reporting memory impairments
Item 1 of 1
Nurses' Note
A 71-year-old male arrives with his daughter with concerns about memory loss. The client's daughter reports that he has forgotten key dates, such as birthdays and his wedding anniversary, over the past six months. She emphasized that he would never forget these dates. Further, the client's daughter also reports that driving has become more difficult and that the client has been involved in two minor accidents over the past six months. He has also misplaced three sets of keys. The daughter describes her father's judgment as 'declining' along with his memory. The client's daughter is concerned that her father may have dementia. The client is alert and fully oriented. The client had difficulty with remote memory questioning. Immediate and recent memory was intact. The client denied any pain or physical symptoms,
stating, "I'm here because my daughter insisted."
Click to specify if the clinical feature is consistent with delirium or dementia: The onset of symptoms is months to years
- A. The onset of symptoms is months to years
- B. May be caused by uncontrolled hypertension and diabetes
- C. Progressively worsens
- D. Memory impairments
- E. May be caused by fluid and electrolyte imbalances or infection
- F. May cause impairments in judgment
- G. Altered level of consciousness
Correct Answer: B,B,B,A,A,A,B
Rationale: Dementia has a gradual onset over months to years.
The nurse is caring for a client newly prescribed ropinirole. The nurse understands that this medication is prescribed to treat which condition?
- A. Multiple Sclerosis
- B. Parkinson disease
- C. Schizophrenia
- D. Guillain-Barré syndrome
Correct Answer: B
Rationale: Ropinirole is a dopamine agonist used to treat Parkinson's disease by improving motor symptoms. It is not indicated for Multiple Sclerosis, Schizophrenia, or Guillain-Barré syndrome, which involve different pathophysiology and treatments.
The primary healthcare provider (PHCP) is preparing to intubate a client. The PHCP prescribes succinylcholine. The nurse understands that this medication is intended to
- A. Sedate the client during the procedure
- B. Decrease oral and airway secretions
- C. Increase heart rate in case of a vagal response
- D. Cause skeletal muscle paralysis
Correct Answer: D
Rationale: Succinylcholine is a depolarizing neuromuscular blocker used to cause skeletal muscle paralysis, facilitating intubation. It does not sedate, reduce secretions, or increase heart rate.
The nurse is preparing a staff in-service regarding sensorineural hearing loss. It would be appropriate for the nurse to identify which factors cause this type of hearing loss?
- A. Presbycusis
- B. Ototoxic substance
- C. Foreign body
- D. Exposure to loud noise
- E. Edema
Correct Answer: A,B,D
Rationale: Presbycusis, ototoxic substances, and loud noise exposure cause sensorineural hearing loss by damaging the inner ear or auditory nerve.
The nurse in the emergency department (ED) is caring for a 20-year-old female client
Item 6 of 6
ED Triage Note
History And Physical
Physician Orders
0912: Client was brought to the ED by her two college roommates 'because she was not acting
right.' The roommate reports that she went to bed the night before reporting stiffness in her
neck and a headache. She attributed it to being under pressure with final exams and having
poor sleep the previous several days. The client apparently took non-prescribed lorazepam
from another roommate to assist her with sleep. The roommate reported recently having
influenza and is unsure if she became infected. It is reported that she declined the influenza
vaccination when it was offered on campus. The roommate reports waking her with physical
stimuli and found her diaphoretic, hot to touch, and mumbling, saying she did not feel well.
Vital signs: T 103.4° F (39.7° C), P 112, RR 12, BP 116/86, pulse oximetry 95% on room air.
Click to highlight the findings below that indicate a worsening of the client's status: The client is lethargic and makes no purposeful movements. Does not respond to physical stimuli. Glasgow coma scale 10. Peripheral pulses 2+. The client's skin is pale and dry. Petechial rash on the torso. Vital signs: T 100.4° F (38° C), P 101, RR 12, BP 117/88, pulse oximetry reading 95%.
- A. Lethargic
- B. no purposeful movements
- C. does not respond to physical stimuli
- D. Glasgow coma scale 10
- E. petechial rash on the torso
Correct Answer: A,B,C,D,E
Rationale: These findings indicate worsening neurological status and possible progression of meningitis.