Med Surg Exam 3

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach any more. It will be too upsetting if I have a seizure at work." How should the nurse respond to specifically address the patient's concern? "You might benefit from some psychologic counseling." "Epilepsy usually can be well controlled with medications." "You will want to contact the Epilepsy Foundation for assistance." "The Department of Vocational Rehabilitation can help with work retraining."

"Epilepsy usually can be well controlled with medications." The nurse should inform the patient that most seizure disorders are controlled with medication. The other information may be necessary if seizures persist after treatment with antiseizure medications is implemented.

The nurse is administering a mental status examination to a patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with "Is that right?" "I don't know." "Wait, let me think about that." "Who are those people over there?"

"I don't know." Answers such as "I don't know" are more typical of depression than dementia. The response "Who are those people over there?" is more typical of the distraction seen in a patient with delirium. The remaining two answers are more typical of a patient with mild to moderate dementia.

The nurse should determine that teaching about migraine headaches has been effective when the patient says which of the following? "I can take the (Topamax) as soon as a headache starts." "A glass of wine might help me relax and prevent a headache." "I will lie down someplace dark and quiet when the headaches begin." "I should avoid taking aspirin and sumatriptan (Imitrex) at the same time."

"I will lie down someplace dark and quiet when the headaches begin." It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines. It must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. How should the nurse respond? "MS symptoms will be worse after the pregnancy." "Women with MS frequently have premature labor." "Symptoms of MS are likely to improve during pregnancy." "MS is associated with an increased risk for congenital defects."

"Symptoms of MS are likely to improve during pregnancy." Symptoms of MS may improve during pregnancy. There is no increased risk for congenital defects in infants born of mothers with MS. Onset of labor is not affected by MS. MS symptoms will not worsen after pregnancy.

A 72-yr-old patient is brought to the clinic by the patient's spouse, who reports that the patient is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? "Are you sad right now?" "How is your self-image?" "What did you eat for lunch?" "Where were you were born?"

"What did you eat for lunch?" This question tests the patient's short-term memory, which is decreased in the mild stage of Alzheimer's disease or dementia. Asking the patient about her birthplace tests for remote memory, which is intact in the early stages. Questions about the patient's emotions and self-image are helpful in assessing emotional status, but they are not as helpful in assessing mental state.

A patient who is having an acute exacerbation of multiple sclerosis has a prescription for methylprednisolone (Solu-Medrol) 150 mg IV. The label on the vial reads: methylprednisolone 125 mg in 2 mL. How many mL should the nurse administer?

2.4 With a concentration of 125 mg/2 mL, the nurse will need to administer 2.4 mL to obtain 150 mg of methylprednisolone.

A patient is being evaluated for Alzheimer's disease (AD). What should the nurse explain to the patient's adult children? Brain atrophy detected by an MRI would confirm the diagnosis of AD. New drugs can reverse AD deterioration dramatically in some patients. The most important risk factor for AD is a family history of the disorder. A diagnosis of AD is made only after other causes of dementia are ruled out.

A diagnosis of AD is made only after other causes of dementia are ruled out. The diagnosis of AD is usually one of exclusion. Age is the most important risk factor for development of AD. Drugs may slow the deterioration but do not reverse the effects of AD. Brain atrophy is a common finding in AD, but it can occur in other diseases as well and does not confirm a diagnosis of AD.

Which prescribed intervention should the emergency department nurse implement first for a patient who is experiencing continuous tonic-clonic seizures? Give phenytoin (Dilantin) 100 mg IV. Monitor level of consciousness (LOC). Administer lorazepam (Ativan) 4 mg IV. Obtain computed tomography (CT) scan.

Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also 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.

Which actions could the nurse delegate to a licensed practical/vocational nurse (LPN/VN) who is part of the team caring for a patient with Alzheimer's disease? (Select all that apply.) Develop a plan to minimize difficult behavior. Administer the prescribed memantine (Namenda). Remove potential safety hazards from the patient's environment. Refer the patient and caregivers to appropriate community resources. Help the patient and caregivers choose memory enhancement methods. Evaluate the effectiveness of enteral nutrition on the patient's nutrition status.

Administer the prescribed memantine (Namenda)., Remove potential safety hazards from the patient's environment. LPN/VN education and scope of practice includes medication administration and monitoring for environmental safety in stable patients. Planning of interventions such as ways to manage behavior or improve memory, referrals, and evaluation of the effectiveness of interventions require registered nurse (RN)-level education and scope of practice.

A 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling-type tremor. What should the nurse anticipate explaining to the patient? Oral corticosteroids Antiparkinsonian drugs Magnetic resonance imaging (MRI) Electroencephalogram (EEG) testing

Antiparkinsonian drugs The clinical diagnosis of Parkinson's is made when tremor, rigidity, akinesia, and postural instability are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? Check the patient's orientation to time and date. Obtain a list of the patient's prescribed medications. Ask the patient to indicate a specific time on a clock drawing. Determine the patient's ability to recognize a common object.

Ask the patient to indicate a specific time on a clock drawing. In the Mini-Cog, patients illustrate a specific time stated by the examiner by drawing the time on a clock face. The other actions may be included in assessment for Alzheimer's disease but are not part of the Mini-Cog exam.

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take? Teach about the use of triptan drugs. Refer the patient for stress counseling. Ask the patient to keep a headache diary. Suggest the use of muscle-relaxation techniques.

Ask the patient to keep a headache diary. The initial nursing action should involve further assessment of precipitating causes of the headaches, quality, and location of pain. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed first.

What should be the nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation? Reorient the patient to time, place, and person. Administer a PRN dose of lorazepam (Ativan). Assess for factors that might be causing discomfort. Assign unlicensed assistive personnel (UAP) to stay in the patient's room.

Assess for factors that might be causing discomfort. Increased motor activity in a patient with dementia is frequently the patient's only way of responding to factors such as pain, so the nurse's initial action should be to assess the patient for any precipitating factors. Administration of sedative drugs may be indicated, but this should not be done until assessment for precipitating factors has been completed and any of these factors have been addressed. Reorientation is unlikely to be helpful for the patient with moderate dementia. Assigning UAP to stay with the patient may also be necessary, but any physical changes that may be causing the agitation should be addressed first.

The nurse observes a patient ambulating in the hospital hall. The patient's arms and legs suddenly jerk and the patient falls to the floor. What action should the nurse take first? Assess the patient for a possible injury. Give the scheduled divalproex (Depakote). Document the timing and description of the seizure. Notify the patient's health care provider about the seizure.

Assess the patient for a possible injury. The patient who has had a myoclonic seizure and fall is at risk for head injury and should first be evaluated and treated for this possible complication. Documentation of the seizure, notification of the health care provider, and administration of antiseizure medications may also be appropriate actions, but the initial action should be assessment for injury.

The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. What is the nurse's most appropriate action? Secure the patient in bed using a soft chest restraint. Ask the health care provider to prescribe an antipsychotic drug. Instruct family members to remain at the patient's bedside and prevent injury. Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient.

Assign unlicensed assistive personnel (UAP) to stay with and reorient the patient. The priority goal is to protect the patient from harm. Having a UAP stay with the patient will ensure the patient's safety. Visits by family members are helpful in reorienting the patient, but families should not be responsible for protecting patients from injury. Antipsychotic medications may be ordered, but only if other measures are not effective because these medications have many side effects. Restraints should be avoided, when possible, because they can increase the patient's agitation and disorientation.

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action should the nurse include in the plan of care? Observe for agitation and paranoia. Assist with active range of motion (ROM). Give muscle relaxants as needed to reduce spasms. Use simple words and phrases to explain procedures.

Assist with active range of motion (ROM). ALS causes progressive muscle weakness. Assisting the patient to perform active ROM will help maintain strength as long as possible. Psychotic manifestations 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.

What action should the nurse incorporate when administering a mental status examination to a patient with delirium? Wait until the patient is well-rested. Administer an anxiolytic medication. Choose a place without distracting stimuli. Reorient the patient during the examination.

Choose a place without distracting stimuli. Because overstimulation by environmental factors can distract the patient from the task of answering the nurse's questions, these stimuli should be avoided. The nurse will not wait to give the examination because action to correct the delirium should occur as soon as possible. Reorienting the patient is not appropriate during the examination. Antianxiety medications may increase the patient's delirium.

What should the nurse advise a patient with myasthenia gravis (MG) to do? Anticipate the need for weekly plasmapheresis treatments. Complete physically demanding activities early in the day. Protect the extremities from injury due to poor sensory perception. Perform frequent weight-bearing exercise to prevent muscle atrophy.

Complete physically demanding activities early in the day. Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for situations in which corticosteroid therapy must be avoided. There is no decrease in sensation with MG. Muscle atrophy does not occur because although there is muscle weakness, they are still used.

Which medication taken by a patient with restless legs syndrome should the nurse discuss with the patient? a. Ibuprofen b. Multivitamin c. Acetaminophen d. Diphenhydramine

Diphenhydramine Antihistamines can aggravate restless legs syndrome. The other medications will not contribute to restless legs syndrome.

A patient tells the nurse about using acetaminophen (Tylenol) several times every day for recurrent bilateral headaches that are present on wakening. Which action should the nurse plan to take first? Discuss the need to stop taking the acetaminophen. Suggest the use of biofeedback for headache control. Describe the use of botulism toxin (Botox) for headaches. Teach the patient about magnetic resonance imaging (MRI).

Discuss the need to stop taking the acetaminophen. 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 the headaches persist.

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse should know that this history is consistent with what type of seizure? Focal-onset Atonic Absence Myoclonic

Focal-onset The initial symptoms of a focal-onset seizure involve clinical manifestations that are localized to a particular part of the body or brain. Symptoms of an absence seizure are staring and a brief loss of consciousness. In an atonic seizure, the patient loses muscle tone and (typically) falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or extremities.

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). What information should the nurse provide when teaching the patient, spouse, and adult children about this disorder? Improved nutrition and exercise can delay disease progression. Levodopa-carbidopa (Sinemet) will help reduce HD symptoms. Prophylactic antibiotics decrease the risk for aspiration pneumonia. Genetic testing is an option for the children to determine their HD risk.

Genetic testing is an option for the children to determine their HD risk. Genetic testing is available to determine whether an asymptomatic person has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD because HD involves an increase in dopamine. Antibiotic therapy will not reduce the risk for aspiration. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? Setting the medications up monthly in a medication box Having the patient's family member administer the medication Posting reminders to take the medications in the patient's house Calling the patient weekly with a reminder to take the medication

Having the patient's family member administer the medication Because the patient with mild dementia will have difficulty with learning new skills and forgetfulness, the most appropriate nursing action is to have someone else administer the drug. The other nursing actions will not be as effective in ensuring that the patient takes the medications.

A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information should the nurse include in patient teaching? Recommendation to drink at least 4 L of fluid daily Need to avoid driving or operating heavy machinery How to draw up and administer injections of the medication? Use of contraceptive methods other than oral contraceptives

How to draw up and administer injections of the medication? Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. There is no need to avoid driving or drink large fluid volumes when taking glatiramer.

Which patient problem should the nurse identify as of highest priority for a patient who has Parkinson's disease and is unable to move the facial muscles? Activity intolerance Inadequate nutrition Disturbed body image Impaired physical mobility

Inadequate nutrition The data about the patient indicate that poor nutrition will be a concern because of decreased swallowing. The other diagnoses may also be appropriate for a patient with Parkinson's disease, but the data do not indicate that they are current problems for this patient.

What action should the nurse include in completing a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS)? Assess for the presence of chest pain. Inquire about urinary tract problems. Inspect the skin for rashes or discoloration. Ask the patient about any increase in libido.

Inquire about urinary tract problems. Urinary tract problems with incontinence or retention are common symptoms of MS. Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with MS.

A patient has been taking phenytoin (Dilantin) for 2 years. Which action should the nurse take when evaluating possible adverse effects of the medication? Inspect the oral mucosa. Listen to the lung sounds. Auscultate the bowel sounds. Check pupil reaction to light.

Inspect the oral mucosa. Phenytoin can cause gingival hyperplasia, but does not affect bowel sounds, lung sounds, or pupil reaction to light.

The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? Keep window blinds open during the day. Have the patient take a mid-morning nap. Provide hourly orientation to time and place. Move the patient to a quiet room in the afternoon.

Keep window blinds open during the day. A likely cause of sundowning is a disruption in circadian rhythms. Keeping the patient active and in daylight will help reestablish a more normal circadian pattern. Moving the patient to a different room might increase confusion. Taking a nap will interfere with nighttime sleep. Hourly orientation will not be helpful in a patient with dementia.

A patient is diagnosed with moderate dementia after multiple strokes. What would the nurse expect to find during assessment of the patient? Excessive nighttime sleepiness. Difficulty eating and swallowing. Loss of recent and long-term memory. Fluctuating ability to perform simple tasks.

Loss of recent and long-term memory. Loss of both recent and long-term memory is characteristic of moderate dementia. Patients with dementia have frequent nighttime awakening. Dementia is progressive, and the patient's ability to perform tasks would not have periods of improvement. Difficulty eating and swallowing is characteristic of severe dementia.

A patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? Encourage the patient to discuss events from the past. Maintain a consistent daily routine for the patient's care. Reorient the patient to the date and time every 2 to 3 hours. Provide the patient with current newspapers and magazines.

Maintain a consistent daily routine for the patient's care. Providing a consistent routine will decrease anxiety and confusion for the patient. Reorientation to time and place will not be helpful to the patient with severe AD, and the patient will not be able to read. The patient with severe AD will probably not be able to remember events from the past.

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient reports nausea and severe abdominal cramps. Which action should the nurse take first? Auscultate the patient's bowel sounds. Notify the patient's health care provider. Administer the prescribed PRN antiemetic drug. Give the scheduled dose of prednisone (Deltasone).

Notify the patient's health care provider. The patient's history and symptoms indicate a possible cholinergic crisis. The health care provider should be notified immediately, and it is likely that atropine will be prescribed. The other actions will be appropriate if the patient is not experiencing a cholinergic crisis.

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? (Select all that apply.) Suggest that a long-term care facility be considered. Offer ideas for ways to distract or redirect the patient. Teach the spouse about adult day care as a possible respite. Suggest that the spouse consult with the physician for antianxiety drugs. Ask the spouse what she knows and has considered about dementia care options.

Offer ideas for ways to distract or redirect the patient, Teach the spouse about adult day care as a possible respite, Ask the spouse what she knows and has considered about dementia care options. The stress of being a caregiverUcanSbeNmanTaged wOith a multicomponent approach. This includes respite care, learning ways to manage challenging behaviors, and further assessment of what the spouse may already have considered for care options. The patient is in the early stages and does not need long-term placement. Antianxiety medications may be appropriate, but other measures should be tried first.

Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consuIt with the health care provider before administration of the medication? Patient has tonic-clonic seizures. Patient experiences an aura before seizures. Patient's most recent blood pressure is 156/92 mm Hg. Patient has slight elevations in liver function test results.

Patient has slight elevations in liver function test results. Many older patients (especially with compromised liver function) may not be able to metabolize phenytoin. The health care provider may need to choose another antiseizure medication. Phenytoin is an appropriate medication for patients with tonic-clonic seizures, with or without an aura. Hypertension is not a contraindication for phenytoin therapy.

After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? Patient who has not had a bowel movement for 5 days. Patient who has a stage II pressure ulcer on the coccyx. Patient who is refusing to take the prescribed medications. Patient who developed a new cough after eating breakfast.

Patient who developed a new cough after eating breakfast. A new cough after a meal in a patient with dementia suggests possible aspiration, and the patient should be assessed immediately. The other patients also require assessment and intervention but not as urgently as a patient with possible aspiration or pneumonia.

After change-of-shift report, which patient should the nurse assess first? Patient with myasthenia gravis who is reporting increased muscle weakness. Patient with a bilateral headache described as "like a band around my head." Patient with seizures who is scheduled to receive a dose of phenytoin (Dilantin). Patient with Parkinson's disease who has developed cogwheel rigidity of the arms.

Patient with myasthenia gravis who is reporting increased muscle weakness. Because increased muscle weakness may indicate the onset of a myasthenic crisis, the nurse should assess this patient first. The other patients should be assessed but do not appear to need immediate nursing assessments or actions to prevent life-threatening complications.

Which hospitalized patient will the nurse assign to the room closest to the nurses' station? Patient with Alzheimer's disease who has long-term memory deficit Patient with vascular dementia who takes medications for depression Patient with new-onset confusion, restlessness, and irritability after surgery Patient with dementia who has an abnormal Mini-Mental State Examination

Patient with new-onset confusion, restlessness, and irritability after surgery This patient's history and clinical manifestations are consistent with delirium. The patient is at risk for safety problems and should be placed near the nurses' station for ongoing observation. The other patients have chronic symptoms that are consistent with their diagnoses but are not at immediate risk for safety issues.

The home health registered nurse (RN) is planning care for a patient with seizure disorder related to a recent head injury. Which action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)? Make referrals to appropriate community agencies. Place medications in the home medication organizer. Teach the patient and family how to manage seizures. Assess for use of medications that may precipitate seizures.

Place medications in the home medication organizer. LPN/VN education includes administration of medications. The other activities require RN education and scope of practice.

A patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? Reorient the patient several times daily. Have the family bring in familiar items. Place the patient in a room close to the nurses' station. Remind the patient not to wander from the nursing unit.

Place the patient in a room close to the nurses' station. Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The patient will not be able to remember not to wander. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.

A patient with Parkinson's disease is admitted to the hospital for treatment of pneumonia. Which interventions should the nurse include in the plan of care? (Select all that apply.) Provide an elevated toilet seat. Cut patient's food into small pieces. Serve high-protein foods at each meal. Place an armchair at the patient's bedside. Observe for sudden exacerbation of symptoms.

Provide an elevated toilet seat., Cut patient's food into small pieces., Place an armchair at the patient's bedside. Because the patient with Parkinson's disease has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's disease is a steadily progressive disease without acute exacerbations.

Which intervention will the nurse include in the plan of care for a patient with moderate dementia who is admitted for other health problems? Provide complete personal hygiene care for the patient. Remind the patient frequently about being in the hospital. Reposition the patient frequently to avoid skin breakdown. Place suction at the bedside to decrease the risk for aspiration.

Remind the patient frequently about being in the hospital. The patient with moderate dementia will have problems with short- and long-term memory and will need reminding about the hospitalization. The other interventions would be used for a patient with severe dementia, who would have difficulty with swallowing, self-care, and immobility.

Which assessment should the nurse identify as most important regarding a patient with myasthenia gravis? Pupil size Grip strength Respiratory effort Level of consciousness

Respiratory effort Because respiratory insufficiency may be life threatening, it will be most important to monitor respiratory function. The other data also will be assessed but are not as critical.

A patient seen in the outpatient clinic is newly diagnosed with mild cognitive impairment (MCI). Which action will the nurse include in the plan of care? Suggest a move into an assisted living facility. Schedule the patient for more frequent appointments. Ask family members to supervise the patient's daily activities. Discuss the preventive use of acetylcholinesterase medications.

Schedule the patient for more frequent appointments. Ongoing monitoring is recommended for patients with MCI. MCI does not usually interfere with activities of daily living, acetylcholinesterase drugs are not used for MCI, and an assisted living facility is not indicated for a patient with MCI.

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply.) Side rail pads Tongue blade Oxygen mask Suction tubing Urinary catheter Nasogastric tube

Side rail pads, Oxygen mask, Suction tubing The patient is at risk for further seizures, and O2 and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention

A hospitalized patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first? Start the prescribed PRN O2 at 6 L/min. Put a moist hot pack on the patient's neck. Give the ordered PRN acetaminophen (Tylenol). Notify the patient's health care provider immediately.

Start the prescribed PRN O2 at 6 L/min. Acute treatment for cluster headache is administration of 100% O2 at 6 to 8 L/min. If the patient obtains relief with the O2, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 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 intervention should the nurse include in the plan of care for a patient who has primary restless legs syndrome (RLS) and is having difficulty sleeping? Teach about the use of antihistamines to improve sleep. Suggest that the patient exercise regularly during the day. Make a referral to a massage therapist for deep massage of the legs. Assure the patient that the problem is transient and likely to resolve.

Suggest that the patient exercise regularly during the day. Nondrug interventions such as getting regular exercise are initially suggested to improve sleep quality in patients with RLS. Antihistamines may aggravate RLS. Massage does not alleviate RLS symptoms, and RLS is likely to progress in most patients.

A patient with Parkinson's disease has bradykinesia. Which action should the nurse include in the plan of care? Instruct the patient in activities that can be done while lying or sitting. Suggest that the patient rock from side to side to initiate leg movement. Have the patient take small steps in a straight line directly in front of the feet. Teach the patient to keep the feet in contact with the floor and slide them forward.

Suggest that the patient rock from side to side to initiate leg movement. 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.

Which action should the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? Encourage decreased evening intake of fluid. Teach the patient how to use the Credé method. Suggest the use of adult incontinence briefs for nighttime only. Assist the patient to the commode every 2 hours during the day.

Teach the patient how to use the Credé method. The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider? The patient drinks 1 to 2 cups of coffee daily. The patient had a recent acute myocardial infarction. The patient has had migraine headaches for 30 years. The patient has taken topiramate (Topamax) for 2 months.

The patient had a recent acute myocardial infarction. Triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none of it indicates that sumatriptan would be an inappropriate treatment.

Which information about a patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)? The patient reports pain with neck flexion. The patient has increased serum creatinine. The patient walks a mile each day for exercise. The patient has the relapsing-remitting form of MS.

The patient has increased serum creatinine. Dalfampridine should not be given to patients with impaired renal function. The other information will not impact whether the dalfampridine should be administered.

A patient hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? The patient was oriented and alert when admitted. The patient's speech is fragmented and incoherent. The patient is oriented to person but disoriented to place and time. The patient has a history of increasing confusion over several years.

The patient was oriented and alert when admitted. The onset of delirium is acute. The degree of disorientation does not differentiate between delirium and dementia. Increasing confusion for several years is consistent with dementia. Fragmented and incoherent speech may occur with either delirium or dementia.

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take? Insert an oral airway during the seizure to maintain a patent airway. Restrain the patient's arms and legs to prevent injury during the seizure. Time and observe and record the details of the seizure and postictal state. Avoid touching the patient to prevent further nervous system stimulation.

Time and observe and record the details of the seizure and postictal state. Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.

After reviewing the health record shown in the accompanying figure for a patient who has multiple risk factors for Alzheimer's disease (AD), which topic will be most important for the nurse to discuss with the patient? Tobacco use Family history Cholesterol level Head injury history

Tobacco use Tobacco use is a modifiable risk factor for AD. The patient will not be able to modify the increased risk associated with family history of AD and past head injury. While the total cholesterol is borderline high, the high HDL indicates that no change is needed in cholesterol management.

A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease. Which assessment finding should indicate to the nurse that a change in the medication or dosage may be needed? Shuffling gait Tremor at rest Cogwheel rigidity of limbs Uncontrolled head movement

Uncontrolled head movement Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.

Which finding should the nurse expect when assessing a patient who is experiencing a cluster headache? Nuchal rigidity Unilateral ptosis Projectile vomiting Bilateral facial pain

Unilateral ptosis Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure. Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? Ask about a family history of dementia. Administer the Mini-Mental Status Exam. Use the Confusion Assessment Method tool. Obtain a list of the patient's usual medications.

Use the Confusion Assessment Method tool. The Confusion Assessment Method tool has been extensively tested in assessing delirium. The other actions will be helpful in determining cognitive function or risk factors for dementia or delirium, but they will not be useful in differentiating between dementia and delirium.

A hospitalized patient reports a bilateral headache (4/10 on the pain scale) that radiates from the base of the skull. Which prescribed PRN medication should the nurse administer initially? lorazepam (Ativan) acetaminophen (Tylenol) morphine sulfate (MS Contin) butalbital and aspirin (Fiorinal)

acetaminophen (Tylenol) The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, which is 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 sulfate and butalbital and aspirin would be more appropriate for a headache that did not respond to a nonopioid analgesic.