Nokea
When the medical history is reviewed, which finding is most likely related to the client's diagnosis?
- A. The client had an influenza immunization in the past week.
- B. The client was bitten by a spider several days ago.
- C. The client drinks fresh, unpasteurized milk daily.
- D. The client sprayed the garden with insecticide yesterday.
Correct Answer: A
Rationale: Guillain-Barré syndrome is often preceded by a viral infection or immunization, such as an influenza vaccine, which can trigger an autoimmune response.
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The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse perform to test the cerebellar function of the client?
- A. With the client’s eyes shut, ask whether the touch with a cotton applicator is sharp or dull.
- B. Ask the client to close the eyes, then hold hands with palms up perpendicular to the body.
- C. Ask the client to grasp and squeeze, with each hand at the same time, the hands of the nurse.
- D. Have the client place the hands on the thighs, then quickly turn the palms up and then down.
Correct Answer: D
Rationale: Detecting sharp or dull touch is a test for peripheral nerve function. Assessing for pronator drift is a test for muscle weakness due to cerebral or brainstem dysfunction. Assessment of hand grasps compares equality of muscle strength bilaterally. Repetitive alternating motion tests the client’s coordination, an indicator of cerebellar function.
The nurse is preparing to administer acetaminophen (Tylenol) to a client diagnosed with a stroke who is complaining of a headache. Which intervention should the nurse implement first?
- A. Administer the medication in pudding.
- B. Check the client's armband.
- C. Crush the tablet and dissolve in juice.
- D. Have the client sip some water.
Correct Answer: B
Rationale: Checking the armband (B) ensures patient safety before medication administration. Pudding (A), crushing (C), or sipping water (D) follow identity confirmation.
The client is prescribed phenytoin (Dilantin), an anticonvulsant, for a seizure disorder. Which statement indicates the client understands the discharge teaching concerning this medication?
- A. I will brush my teeth after every meal.'
- B. I will check my Dilantin level daily.'
- C. My urine will turn orange while on Dilantin.'
- D. I won’t have any seizures while on this medication.'
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, so good oral hygiene (A) is essential and indicates understanding. Dilantin levels (B) are checked periodically by providers, not daily. Urine color change (C) is not typical, and seizures may still occur (D) if not fully controlled.
The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?
- A. An oral anticoagulant medication.
- B. A beta blocker medication.
- C. An anti-hyperuricemic medication.
- D. A thrombolytic medication.
Correct Answer: A
Rationale: A TIA in a client with atrial fibrillation is likely due to cardioembolic stroke risk. Oral anticoagulants (A), such as warfarin or direct oral anticoagulants, are prescribed to prevent clot formation. Beta blockers (B) control heart rate, anti-hyperuricemics (C) treat gout, and thrombolytics (D) are used acutely, not for discharge prevention.
The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?
- A. Brain CT scan results show no bleeding.
- B. Had a serious head injury four weeks ago.
- C. Has a history of type 1 diabetes mellitus.
- D. Neurological deficits started 2 hours ago.
Correct Answer: B
Rationale: A negative CT scan is a criterion for administering the thrombolytic therapy. Contraindications to thrombolytic therapy for the client with an ischemic stroke include a serious head injury within the previous 3 months. This would put the client at risk of developing serious bleeding problems, specifically cerebral hemorrhage. History of type 1 DM is not a contraindication for thrombolytic therapy. The onset of neurological deficits within 3 hours is a criterion for administering thrombolytic therapy.