Nokea
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.
You may also like to solve these questions
Select the three (3) prescriptions/orders the nurse should anticipate for this client
- A. Computed tomography scan of the brain
- B. Capillary blood glucose
- C. Lumbar puncture
- D. Arterial blood gas (ABG)
- E. Heparin by continuous IV infusion
- F. Nothing by mouth (NPO) status
- G. 500 mL of 0.9% saline
Correct Answer: A,B,F
Rationale: CT scan, CBG, and NPO status are critical for suspected stroke to assess brain injury, rule out hypoglycemia, and prepare for possible thrombolytics.
The nurse is developing a plan of care for a client with advanced Alzheimer's disease. Which of the following should the nurse include?
- A. Assess the client's risk for falls
- B. Monitor the client for hyperorality
- C. Provide consistent caregivers
- D. Obtain a prescription for as-needed (PRN) diphenhydramine
- E. Foster a low-stimulation environment
- F. Offer limited choices
Correct Answer: A,B,C,E,F
Rationale: These interventions address safety, behavior, and comfort in advanced Alzheimer's disease.
The nurse is caring for a client with Huntington's disease. Which of the following assessment findings would be expected?
- A. Halitosis
- B. Chorea
- C. Hallucinations
- D. Hematemesis
- E. Weight loss
Correct Answer: B,E
Rationale: Chorea (involuntary movements) and weight loss are hallmark symptoms of Huntington's disease.
The nurse in the emergency department (ED) is caring for a 26-year-old female client.
Item 1 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 is assessing the client with a persistent headache. Which two (2) findings from the client's history and physical examination are most concerning and require immediate intervention?
- A. Headache described as throbbing and located behind the left eye
- B. Visual disturbances, including flashes of light and blurred vision
- C. Confusion and difficulty speaking
- D. Persistent nausea despite normoactive bowel sounds
- E. Use of escitalopram and buspirone for generalized anxiety disorder
- F. Right arm weakness
Correct Answer: C,F
Rationale: Confusion, difficulty speaking, and right arm weakness suggest a possible stroke or other serious neurological condition, requiring immediate intervention. Throbbing headache, visual disturbances, nausea, and medication use are less urgent.
The nurse is assessing a client taking prescribed lamotrigine. Which client finding requires immediate follow-up?
- A. Abnormal dreams
- B. Skin blistering
- C. Dyspepsia
- D. Xerostomia
Correct Answer: B
Rationale: Skin blistering is a serious adverse effect of lamotrigine, potentially indicating Stevens-Johnson syndrome or toxic epidermal necrolysis, both life-threatening conditions requiring immediate medical attention. Abnormal dreams, dyspepsia, and xerostomia are less severe side effects that do not typically require urgent follow-up.