Nokea
This nurse is caring for a client who is receiving prescribed carbamazepine. Which of the following findings would indicate a therapeutic response?
- A. Decreased mood lability
- B. Steady gait
- C. Urinary continence
- D. Increased bone mass
Correct Answer: B
Rationale: Carbamazepine is an anticonvulsant used for seizures, and a steady gait indicates reduced seizure activity or improved neurological stability. Mood lability, urinary continence, and bone mass are not primary therapeutic outcomes.
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The following scenario applies to the next 1 items
The nurse is caring for a 71-year-old female in the emergency department (ED)
Item 1 of 1
Nurses' Note Diagnostics
1425: 71-year-old female arrives via EMS with a concern about a stroke. At approximately 1350 a client was at lunch with her family and suddenly stopped talking and fell to the right side. The client was unable to speak or follow verbal commands on the scene. Vital signs on arrival: 98.7° F (37.1° C), P 88, RR 18, BP 182/96. The client can blink her eyes and cannot follow verbal commands or express words. She is instructed to move each extremity but does not make any movement. Pupils are equal, round, and reactive to light. Right-sided facial drooping was noted. The client has a medical history of osteoarthritis, hypertension, and atrial fibrillation.
1427: A stroke alert was initiated at this time, and the client was transported to radiology for a STAT CT scan.
1438: Computed tomography scan completed. Physician at bedside evaluating the client and the results.
1444: Physician gave a verbal order for alteplase 0.9 mg/kg intravenous (IV) infuse over sixty minutes with a 10% alteplase bolus dosage given over one minute
The nurse reviews the nurses' note entries from 1425, 1427, 1438, and 1444 and plans care for this client indicated
For each potential nursing intervention, click to specify if the intervention is indicated or not Indicated:
- A. Obtain an accurate weight
- B. Insert two peripheral vascular access devices
- C. Insert a nasogastric tube (NGT) immediately after alteplase infusion
- D. Obtain baseline laboratory work (CBC, CMP, aPTT, PT/INR) prior to infusion of alteplase
- E. Plan for admission to the medical-surgical floor
- F. Perform frequent neurological assessments
- G. Notify the physician if the systolic blood pressure is 185 mm Hg or greater
Correct Answer: A,A,B,A,B,A
Rationale: Accurate weight is critical for calculating the correct dose of alteplase for stroke treatment. Two peripheral IVs are needed for alteplase administration to ensure reliable access for the thrombolytic and other medications. NGT insertion is not immediately indicated post-alteplase unless swallowing difficulties are confirmed, to avoid complications. Baseline labs are essential to assess bleeding risk before administering thrombolytics like alteplase. Stroke patients receiving alteplase typically require ICU admission for close monitoring, not a medical-surgical floor. Frequent neurological assessments are critical post-alteplase to monitor for neurological changes or complications.
The nurse is teaching a group of students about contributing factors for delirium. The nurse is correct in identifying that delirium can be caused by:
- A. Fever
- B. Alzheimer's disease
- C. Hypoglycemia
- D. Vascular disease
- E. Infection
Correct Answer: A,C,E
Rationale: Fever, hypoglycemia, and infection are reversible causes of delirium, unlike Alzheimer's, which causes dementia.
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 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.
The ICU nurse assesses a comatose patient with a known lesion to the medulla. Which breathing pattern would the nurse expect to assess?
- A. Cheyne-Stokes
- B. Apneustic breathing
- C. Central neurogenic hyperventilation
- D. Cluster breathing
Correct Answer: B
Rationale: Medulla lesions often cause apneustic breathing, characterized by prolonged inspiratory pauses.