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 nurse is caring for a client diagnosed with Multiple Sclerosis (MS). The nurse should anticipate a prescription for which medication?
- A. Topiramate
- B. Risperidone
- C. Prazosin
- D. Baclofen
Correct Answer: D
Rationale: Baclofen is a muscle relaxant commonly prescribed for spasticity in Multiple Sclerosis. Topiramate is used for seizures or migraines, risperidone for psychiatric conditions, and prazosin for hypertension, none of which are primary treatments for MS.
Minutes after administering an intravenous dose of 10 mg of morphine, the nurse notes that the client's blood pressure has dropped from 122/83 mmHg to 88/67 mmHg, and the client's respirations are now 8/minute. Which nursing action is the most appropriate?
- A. Prepare for intubation
- B. Prepare to administer a dopamine infusion
- C. Administer naloxone
- D. Start an intravenous infusion of normal saline
Correct Answer: C
Rationale: Naloxone reverses opioid-induced respiratory depression and hypotension, which are evident here.
The nurse is caring for an older adult with advanced dementia. The client asks about her deceased sister, 'When will my sister come to visit me this afternoon?' Which is the best response from the nurse?
- A. This is so sad. I'm sorry to tell you but your sister died last year.'
- B. She won't be coming to visit today.'
- C. I understand you want her to visit you. Where did you and your sister grow up?'
- D. Wait and see if she comes to visit today.'
Correct Answer: C
Rationale: Redirecting the conversation compassionately avoids distress and engages the client with dementia.
The nurse is discussing biological clocks with another nurse. What term is used to describe a human's innate biological clock relating to daytime and nighttime wakefulness and activity?
- A. REM sleep
- B. Circadian rhythm
- C. Diurnal rhythm
- D. Nocturnal activity
Correct Answer: B
Rationale: Circadian rhythm refers to the body's 24-hour cycle regulating sleep and wakefulness.
The following scenario applies to the next 1 items
The emergency department nurse is caring for a 27-year-old male client.
Item 1 of 1
Nurses' Notes
1500: Client reports an 'excruciating' headache right behind his left eye. He says the pain is 'pulsating' and worse when lying down. He reports sensitivity to lights and sounds. He reports getting these headaches daily for the past two weeks at about the same time. He states that the headache lasts one to two hours. On assessment, the client appears in moderate distress; he is alert, oriented, and has tearing in his left eye. His gait was steady as he paced around the exam room because having him sit down to obtain vital signs increased his pain. Lung sounds are clear; peripheral pulses were 2+. Normoactive bowel sounds. He reports his pain rated 9/10 on the Numerical Rating Scale.
The client is demonstrating clinical manifestations consistent with
- A. Cluster headache
- B. Tension headache
- C. Trigeminal neuralgia
- D. Migraine headache
Correct Answer: A
Rationale: The symptoms (excruciating unilateral headache, tearing, sensitivity to light/sound) are characteristic of cluster headaches.