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Which action will the nurse take when evaluating a patient who is taking phenytoin for adverse effects of the medication?
- A. Inspect the oral mucosa.
- B. Listen to the lung sounds.
- C. Auscultate the bowel tones.
- D. Check pupil reaction to light.
Correct Answer: A
Rationale: Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light.
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The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS) who is hospitalized with pneumonia. Which of the following actions should the nurse take?
- A. Assist with active range of motion
- B. Observe for agitation and paranoia
- C. Give muscle relaxants as needed to reduce spasticity
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness. Patients should be guided to use moderate-intensity, endurance-type exercises for the trunk and limbs, since this may help reduce ALS spasticity. When hospitalized with other health concerns, it is important to complete ROM to maintain strength. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.
The nurse is caring for a hospitalized patient who has a moderate bilateral headache that radiates from the base of the skull. Which of the following prescribed PRN medications should the nurse administer initially?
- A. Lorazepam
- B. Acetaminophen
- C. Morphine sulphate
- D. Butalbital and Aspirin
Correct Answer: B
Rationale: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulphate or butalbital and Aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.
The nurse is caring for a patient with multiple sclerosis (MS) who has urinary retention caused by a flaccid bladder. Which of the following actions should the nurse plan to take?
- A. Teach the patient how to perform self-catheterization
- B. Decrease the patient's fluid intake in the evening
- C. Suggest the use of incontinence briefs for nighttime use only
- D. Assist the patient to the commode every 2 hours during the day.
Correct Answer: A
Rationale: Bladder control is a major problem for many patients with MS. Although anticholinergics may be beneficial for some patients to decrease spasticity, other patients may need to be taught self-catheterization. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.
The nurse is caring for a patient with a history of cluster headache who awakens during the night with a severe stabbing headache. Which of the following actions should the nurse take first?
- A. Start the prescribed PRN oxygen at 8 L/minute.
- B. Put a moist hot pack on the patient's neck.
- C. Give the prescribed PRN acetaminophen.
- D. Notify the patient's health care provider immediately.
Correct Answer: A
Rationale: Acute treatment for cluster headache is administration of 100% oxygen at 8-12 L/min for 15 minutes. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60-90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.
Which of the following information about a patient who is being treated with carbidopa/levodopa for Parkinson's disease is most important for the nurse to report to the health care provider?
- A. Shuffling gait
- B. Tremor at rest
- C. Cogwheel rigidity of limbs
- D. Uncontrolled head movement
Correct Answer: D
Rationale: Dyskinesia is an adverse effect of the carbidopa/levodopa, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.