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Which of the following prescribed interventions will the nurse implement first for a hospitalized patient who is experiencing continuous tonic-clonic seizures?
- A. Give phenytoin 100 mg IV.
- B. Monitor level of consciousness.
- C. Obtain computed tomography scan.
- D. Administer lorazepam 4 mg IV.
Correct Answer: D
Rationale: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure drugs such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin also will be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.
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The nurse is teaching a patient with Parkinson's disease preventive measures to reduce the risk of a fall. Which of the following instructions should the nurse include in the teaching session?
- A. Point the toes downward when stepping.
- B. Take two steps backward and three steps forward.
- C. Rock from front to back when walking.
- D. Drop rice kernels and step over them.
Correct Answer: D
Rationale: Patients who are at risk for falling and tend to freeze while walking are at risk of falling. Have the patient learn to drop rice kernels and focus on stepping over them to help prevent falls. Other measures include: pointing the toes upward, take one step backwards and two steps forward, and, rock from side to side, rather than from front to back.
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.
The nurse is assessing a patient at the health clinic who has a severe migraine headache and tells the nurse about having four similar headaches in the last 3 months. Which of the following actions should the nurse take initially?
- A. Refer the patient for stress counselling.
- B. Ask the patient to keep a headache diary.
- C. Suggest the use of muscle-relaxation techniques.
- D. Teach about the effectiveness of the triptan drugs.
Correct Answer: B
Rationale: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality, and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.
A patient tells the nurse about using acetaminophen several times every day for recurrent bilateral headaches. Which of the following actions should the nurse take first?
- A. Discuss the need to stop taking the acetaminophen.
- B. Suggest the use of biofeedback for headache control.
- C. Teach the patient about magnetic resonance imaging (MRI).
- D. Describe the use of botulism toxin (BOTOX) for headaches.
Correct Answer: A
Rationale: The headache description suggests that the patient is experiencing medication overuse headache. The initial action will be withdrawal of the medication. The other actions may be needed if headaches persist.
A patient with Parkinson's disease has a nursing diagnosis of impaired physical mobility related to bradykinesia. Which of the following actions should the nurse include in the plan of care?
- A. Instruct the patient in activities that can be done while lying or sitting.
- B. Suggest that the patient rock from side to side to initiate leg movement.
- C. Have the patient take small steps in a straight line directly in front of the feet.
- D. Teach the patient to keep the feet in contact with the floor and slide them forward.
Correct Answer: B
Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.