234 Unit 2 Ticket to Test

A patient with chronic heart failure receives a prescription for an angiotensin-converting enzyme (ACE) inhibitor. The nurse would monitor the patient for which major side effect? 1 Angioedema 2 Hypokalemia 3 Inability to swallow 4 Symptomatic hypertension

1 A major side effect of ACE inhibitors is angioedema, which is an allergic condition involving edema of the face and airways. It is a life-threatening condition. Other major side effects include symptomatic hypotension, intractable cough, hyperkalemia, and renal insufficiency.

Which condition increases a patient's risk for digoxin toxicity? 1 Hypokalemia 2 Hypocalcemia 3 Hyperuricemia 4 Hypermagnesemia

1 Being hypokalemic makes a patient more prone to digoxin toxicity. For this reason, the nurse should withhold the dose and report the potassium level. The health care provider may prescribe the digoxin to be given once the potassium level has been treated and increased to the normal range. Hypercalcemia and hypomagnesemia can also trigger digitalis toxicity. Hyperuricemia does not put the patient at risk for digitalis toxicity.

****When providing care for a patient with advanced Huntington's disease (HD), which interventions would the nurse implement? 1 Provide palliative care as the collaborative approach. 2 Provide a fluid diet, including enteral or parenteral nutrition to meet caloric needs. 3 Provide a comfortable environment by maintaining physical safety. 4 Provide documents for the patient to determine personal advance directives. 5 Provide a low-calorie diet, not more than 2000 calories/day to prevent weight gain.

1 Choreic movements are the clinical manifestations of HD. Therefore, caloric requirements can be as high as 4000 to 5000 calories/day to maintain a patient's body weight. As the disease progresses, provide enteral or parenteral nutrition to meet caloric needs. Providing a fluid diet may help the patient to swallow more easily and prevent complications such as aspiration. There is no cure for HD, so the collaborative care would be palliative. Maintain physical safety for the patient and caregiver by providing a comfortable environment. Provide documents for the patient to determine personal advance directives regarding cardiopulmonary resuscitation (CPR), artificial feedings, antibiotics, and so forth much earlier in the disease process, not during the advanced phase. The patient is not in danger of becoming obese as the chorea demands a high caloric requirement.

Defibrillation is indicated for which dysrhythmia? 1 Ventricular fibrillation 2 Uncontrolled atrial fibrillation 3 Ventricular tachycardia with a pulse 4 Third-degree atrioventricular (AV) block

1 Defibrillation is always indicated in the treatment of ventricular fibrillation. Drug treatments are normally used in the treatment of uncontrolled atrial fibrillation and for ventricular tachycardia with a pulse (if the patient is stable). Otherwise, synchronized cardioversion is used, as long as the patient has a pulse. Pacemakers are the treatment of choice for third-degree heart block.

The nurse is caring for a patient with acute decompensated heart failure (ADHF) who is experiencing volume overload. The nurse would anticipate a prescription for which type of drug? 1 Diuretic 2 Narcotic 3 Antidysrhythmic 4 Positive inotrope

1 Diuretics are the preferred treatment for patients with ADHF experiencing volume overload because they decrease fluid volume and provide other benefits as well. A narcotic may be used to treat pain and anxiety, not volume overload. Antidysrhythmics are used to treat dysrhythmias, not volume overload. Positive inotropes act on the cardiovascular system to treat other implications of heart failure, not volume overload.

Which situation is indicated by the presence of bilateral fine crackles in a patient with acute decompensated heart failure (ADHF)? 1 Fluid in the alveoli 2 Mucus in the alveoli 3 Bronchoconstriction 4 Upper airway obstruction

1 Fluid in the alveoli is the correct answer because crackles are made by the sound of air moving through fluid-filled alveoli. Mucus in the airways sounds like rhonchi or would cause diminished lung sounds if there were consolidation. Bronchoconstriction results in wheezing. Upper airway obstruction results in stridor or, in complete obstruction, an absence of breath sounds.

The nurse reviews the laboratory results of a patient with heart failure (HF) who has a prescription for digoxin. The nurse would decide to withhold the medication based on abnormal findings of which blood study? 1 Potassium 2 Thyroid function tests 3 White blood cells (WBCs) 4 Blood urea nitrogen (BUN)

1 Low serum potassium enhances the action of digitalis, causing a therapeutic dose to reach toxic levels. Similarly, hyperkalemia inhibits the action of digitalis, resulting in a subtherapeutic dose. The serum potassium levels of all patients taking digitalis are monitored. The results of a BUN, WBCs, or thyroid function tests do not affect the nurse's decision to administer or withhold digoxin.

A patient with a newly inserted permanent pacemaker receives discharge instructions from the nurse. Which patient statement indicates that further teaching is required? 1 "I should avoid using microwave ovens." 2 "I should avoid standing near antitheft devices." 3 "I should avoid direct blows to the pacemaker site." 4 "I should avoid close proximity to high-output electric generators."

1 Microwaves do not interfere with a pacemaker's function and can be used safely. Electric signals from antitheft devices can affect pacemaker functioning. The patient should avoid direct blows to the pacemaker site to reduce pressure at the site. Electric signals from high-output electric generators can move the pacemaker from its position and affect its functioning.

When planning the care for a patient with multiple sclerosis who has an exacerbation of sensory deficits, for which patient problem would the nurse develop nursing interventions? 1 Risk for injury 2 Acute confusion 3 Fluid volume deficit 4 Ineffective thermoregulation

1 Multiple sclerosis usually exhibits itself on one side more than the other. Therefore the gait is unsteady, so there is an increase in the patient's fall risks. Acute confusion may be a manifestation experienced by some patients later in the multiple sclerosis disease process. Deficient fluid volume and ineffective thermoregulation are not characteristics of multiple sclerosis. Visual disturbances and muscle spasticity may also contribute to the patient's potential risk for injury.

The nurse educates a patient with heart failure (HF) about lifestyle changes to avoid complications. Which statement made by the patient indicates that further teaching is needed? 1 "I can add salt to my food and eat what I want." 2 "I can eat hard candy or ice pops to avoid thirst." 3 "I shouldn't exercise or do anything to strain my heart." 4 "I will take all of my medications at the prescribed times."

1 Not following a low-sodium diet may lead to complications such as hypertension, edema, and other conditions. Fluid restriction is not usually prescribed for the patient with mild to moderate HF. However, in chronic HF, fluids are limited to 2 L/day. The use of ice pops and hard candy helps avoid thirst, which is a side effect of HF medications. Lack of exercise does not increase a patient's sodium level. Taking medication at the prescribed times is correct and does not need further teaching.

Which medication, taken by a patient with a history of epilepsy, would the nurse associate with gingival enlargement? 1 Phenytoin (Dilantin) 2 Gabapentin (Neurontin) 3 Clonazepam (Klonopin) 4 Valproic acid (Depakene)

1 Phenytoin, gabapentin, clonazepam, valproic acid, and carbamazepine are the drugs used in treating epilepsy. Gingival enlargement is a common side effect of phenytoin; therefore a patient with epilepsy who is using phenytoin may experience gingival enlargement. Gabapentin, clonazepam, and valproic acid do not cause gingival enlargement.

For the patient receiving initial medications for treatment of multiple sclerosis, which medication would the nurse associate with the patient's reports of flu-like symptoms, depressed feelings, and frequent thoughts of committing suicide? 1 β-1a interferon (Rebif) 2 Natalizumab (Tysabri) 3 Mitoxantrone (Novantrone) 4 Dalfampridine (Ampyra)

1 β-interferon is an immunomodulator prescribed in the initial treatment of multiple sclerosis and known to cause flu-like symptoms, depression, and suicidal ideations. Natalizumab treats patients with active and aggressive forms of multiple sclerosis, and this drug is not part of initial treatment. The major risk factor associated with this drug therapy is progressive multifocal leukoencephalopathy. Mitoxantrone treats patients with active and aggressive forms of multiple sclerosis, not in the initial treatment. The risk factors associated with this drug are cardiotoxicity, leukemia, and infertility. Dalfampridine improves walking speed.

When performing a physical assessment on a patient with amyotrophic lateral sclerosis (ALS), which clinical manifestations would the nurse identify? Select all that apply. 1 Limb weakness 2 Difficulty swallowing 3 Difficulty articulating words 4 Twisting movements of the face 5 Involuntary movements of the body

123 Amyotrophic lateral sclerosis is a rare, progressive neurologic disorder characterized by loss of motor neurons. Characteristics of the disease are limb weakness, difficulty in articulating words (dysarthria), and difficulty in swallowing (dysphagia). The symptoms are due to denervation of the muscles and lack of stimulation and use. Twisting movements of the face and involuntary movements of the body do not occur in amyotrophic lateral sclerosis.

Which findings will the nurse likely observe when a patient has right-sided heart failure (HF)? Select all that apply. 1 Distended neck veins 2 Enlarged cardiac muscle 3 Engorged or enlarged liver 4 Decreased afterload in the ventricle 5 Decreased resistance to blood ejection

123 Right-sided HF occurs when the right ventricle (RV) does not pump effectively. When the RV fails, fluid backs up into the venous system. This causes movement of fluid into the tissues and organs (e.g., distended neck veins, enlarged cardiac muscle, engorged or enlarged liver, peripheral edema, abdominal ascites). Right-sided HF increases resistance to blood flow and increases afterload.

*******A patient reports a fluttering feeling in the chest. The nurse assesses a rhythm of supraventricular tachycardia (PSVT), a heart rate of 150 beats per minute, and a BP of 120/60 mm Hg. Which treatments would the nurse expect to be added to the patient's plan of care? Select all that apply. 1 Vagal stimulation 2 IV β-blockers 3 IV adenosine 4 Emergent cardioversion 5 IV calcium channel blockers

1235 Common vagal maneuvers include Valsalva, carotid massage, and coughing. Medications that may be used include β-blockers, adenosine, calcium channel blockers, and amiodarone. These drugs have impact on various phases of action potential. Adenosine decreases conduction through the atrioventricular (AV) nodes. β-blockers decrease automaticity of the sinoatrial (SA) node. If the patient becomes hemodynamically unstable and symptomatic, emergent cardioversion is considered.

Which information would the nurse provide the caregiver of a patient with acute seizures regarding actions to implement if another seizure occurs at home? Select all that apply. 1 Ease the patient to the floor. 2 Loosen constrictive clothes. 3 Restrain the patient to a bed. 4 Protect the patient from any injury. 5 Bring the patient to the hospital immediately.

124 During an acute seizure, the most important thing is to ease the patient to the floor, if seated, and loosen constrictive clothing. Protect the patient from any potential injury. The chances of injury are higher if restraining the patient. It is not necessary to bring the patient to the hospital immediately. Once the seizures have stopped and the patient becomes stable, then transport the patient to the hospital.

****To promote self-care and independence in patients with Parkinson's disease, which interventions would the nurse provide family members? Select all that apply. 1 Have the patient wear slip-on shoes. 2 Provide the patient with an elevated toilet seat. 3 Use rugs on the floor to keep the patient's feet warm. 4 Examine the patients clothing and use items with buttons and hooks. 5 Encourage the patient to elevate the legs on an ottoman when sitting

125 To promote self-care and independence of the patient, identify potential changes in the home environment. The patient should use slip-on shoes because the patient can be easily put them on or taken them off. Elevated toilet seats help with getting on and off the toilet easily. Elevate legs on an ottoman prevents ankle edema. Remove rugs because they can cause the patient to fall. Hooks and buttons as clothing fasteners may be difficult for the patient to use; instead, use clothing with hook-and-loop (Velcro) fasteners or zippers.

******When a patient has a new prescription of phenytoin (Dilantin) for seizures, the nurse would provide information for which common side effects of the medication? Select all that apply. 1 Hirsutism 2 Neuropathy 3 Weight gain 4 Memory loss 5 Gingival hyperplasia

15 Gingival hyperplasia and hirsutism are the most common side effects of phenytoin. Good dental hygiene, including regular tooth brushing and flossing, can limit gingival hyperplasia. The drug is not associated with neuropathy, memory loss, or weight gain.

Which information would the nurse include in the dietary education for a patient with heart failure (HF)? 1 A list of foods high in thiamine 2 Guidelines for a low-sodium diet 3 Recommendations for a high-protein diet 4 Instructions for fluid restriction of less than 500 mL per day

2 A low-sodium diet is advised for patients with HF. High levels of thiamine are not part of the dietary plan for patients with HF. Protein levels should not be increased for patients with HF. Fluid restrictions are not necessary for all patients and would not be as low as 500 mL.

Which finding in the medical record of a patient with heart failure (HF) is not consistent with the patient's diagnosis? 1 Fatigue 2 Bradycardia 3 Clammy and cold skin 4 Paroxysmal nocturnal dyspnea

2 Bradycardia is not related to acute decompensated heart failure (ADHF) or chronic heart failure. Fatigue is an indication associated with chronic heart failure. Clammy and cold skin is a result of vasoconstriction during ADHF. Paroxysmal nocturnal dyspnea is also associated with chronic heart failure.

A patient who takes digitalis receives a prescription for another new medication. Which medication would cause the nurse to monitor electrolytes more frequently? 1 Nitrate 2 Diuretic 3 β-Adrenergic receptor blocker (β-blocker) 4 Angiotensin-converting enzyme (ACE) inhibitor

2 Diuretics can either waste or spare potassium, causing hypokalemia or hyperkalemia, both of which can cause issues when occurring in the patient on digitalis. Nitroglycerin and ACE inhibitors do not affect the levels of electrolytes. The combination of a β-blocker and digitalis can cause a decrease in the heart rate but not an electrolyte imbalance.

For the patient with Parkinson's disease who has difficulty swallowing, which intervention would the nurse initially include in the patient's plan of care? 1 Arrange for someone to feed the patient. 2 Provide the patient with semisolid or soft foods. 3 Encourage the patient to drink fluids with meals. 4 Place food into the unaffected side of the patient's mouth

2 In Parkinson's disease, the patient may have poor control of the tongue, increasing the risk for aspiration. Semisolid food without lumps and thickened liquids stick together, allowing the tongue to direct the food bolus to the back of the mouth. Encourage the patient to self-feed to maintain independence and function. Clear fluids with meals at any time may present a risk of aspiration if there is difficulty swallowing. Parkinson's disease likely affects the tongue and entire mouth, so placing food into the unaffected side of the patient's mouth is not an appropriate choice.

Which medication classification would the nurse expect of a new medication prescribed to treat the major symptoms of a patient's multiple sclerosis (MS)? 1 Antipsychotics 2 Muscle relaxant 3 Antihypertensive 4 Narcotic analgesic

2 MS causes muscle spasticity as loss of the myelin sheath progresses. Muscle relaxants ease these spasms. Use of antihypertensives does not occur routinely when treating MS; hypertension is not related to MS. Use of narcotic analgesics treats severe pain, which is usually not associated with MS. Use of antipsychotics occurs sometimes in the treatment of Huntington's disease, not MS.

A patient's apical heart rate is 45 beats/minute. Which scheduled medication would the nurse withhold? 1 Morphine 2 Metoprolol 3 Furosemide 4 Rosuvastatin

2 Metoprolol, which is a β-adrenergic receptor blocker, inhibits the sympathetic nervous system, causing a decrease in heart rate; therefore this drug should be withheld, and the health care provider must be notified. Diuretics, such as furosemide, are used to reduce edema, pulmonary venous pressure, and preload; the pulse rate is not affected. Morphine is used to reduce pain and anxiety, and it also decreases preload and afterload; it may be given if the patient is in pain and has a heart rate of 45 beats/min. Antihyperlipidemic drugs, such as rosuvastatin, are used to help control cholesterol in the patient; a heart rate of 45 beats/min does not indicate that it should be withheld.

For patients with amyotrophic lateral sclerosis (ALS), which treatment goal focuses on preventing a common cause of death in patients with ALS? 1 Reduced fat intake 2 Reduced risk of aspiration 3 Decreased injury related to falls 4 Decreased pain secondary to muscle weakness

2 Reducing the risk of aspiration can help to prevent respiratory infections that are a common cause of death from deteriorating muscle function. Reducing fat intake may reduce cardiovascular disease, but this is not a common cause of death for patients with ALS. Decreasing injury related to falls and decreasing pain secondary to muscle weakness are important nursing interventions for patients with ALS but are unrelated to causes of death for these patients.

For the patient with recent seizure activity, which characteristic would the nurse associate with a focal seizure? 1 The patient lost consciousness during the seizure. 2 The seizure involved lip smacking and repetitive movements. 3 The patient fell to the ground and became stiff for 20 seconds. 4 The etiology of the seizure involved both sides of the patient's brain.

2 The most common complex focal seizure involves lip smacking and automatisms (repetitive movements that may not be appropriate). Loss of consciousness, bilateral brain involvement, and a tonic phase are associated with generalized seizure activity.

*****During an acute exacerbation of the patient's multiple sclerosis, which interventions would the nurse implement? Select all that apply. 1 Assist the patient with the grieving process. 2 Prevent the complication of pressure ulcers. 3 Prevent the complication of urinary tract infections. 4 Teach the patient to build a general resistance to illness. 5 Teach the patient to maintain a good balance between exercise and rest.

23 A patient experiencing an acute exacerbation of multiple sclerosis may be immobile and confined to bed. The first nursing interventions in this phase target the prevention of major complications associated with immobility. Pressure ulcers may occur due to the immobility of the patient while confined to the bed. Implement immediate care to prevent this. Urinary tract infections are also common due to the stagnation of urine. Assisting the patient with the grieving process is an important intervention during the diagnostic phase of multiple sclerosis but is not applicable to a patient with an acute exacerbation of the disease. Teaching the patient to build general resistance to illness is a general intervention for a patient suffering from multiple sclerosis. Teaching the patient to maintain a good balance between exercise and rest is a general intervention for a patient with multiple sclerosis but is not applicable for patients who are immobile.

Which instruction would the nurse include in discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD)? Select all that apply. 1 Avoid or limit air travel. 2 Obtain and wear a Medic Alert ID device at all times. 3 Avoid large magnets and strong electromagnetic fields. 4 Avoid lifting the arm on ICD side above the shoulder until approved. 5 Do not walk through antitheft devices in doorways of stores and public buildings.

234 Patients with ICDs need to obtain and wear a Medic Alert ID device at all times, avoid large magnets and strong electromagnetic fields because they may interfere with ICD function, and avoid lifting their arms on the ICD side above their shoulders until approved. These patients do not need to avoid air travel. They can walk through antitheft devices at a normal pace but should not stand next to them.

*******A patient undergoing treatment for dysrhythmia is provided with a Holter monitor. Which information would the nurse include in the patient teaching about the test? Select all that apply. 1 The patient should activate the monitor when experiencing symptoms. 2 The patient should record activities and any symptoms in a diary. 3 The monitor records the electrocardiogram (ECG) when the patient is ambulatory. 4 New technology using smart phone apps can obtain and save ECG recordings. 5 The monitor records the ECG when the patient performs daily activities.

2345 The patient should keep a diary and record activities and any symptoms. The Holter monitor continuously records the ECG while the patient is ambulatory and performing daily activities. New technology using smart phone apps can obtain and save ECG recordings and even detect some dysrhythmias. The patient would not wait to activate the monitor when having symptoms, which the Holter monitor records continuously. Event monitors are activated only when having symptoms.

Which patient statements regarding Huntington's disease and related genetic testing indicate understanding of the disease? Select all that apply. 1 Positive genetic testing also indicates the age of symptom onset. 2 Currently, there is no effective treatment or cure for Huntington's disease. 3 Positive genetic testing indicates that the patient will eventually develop the disease. 4 Diagnosis occurs prior to having children and potentially transmitting the disease genetically. 5 Offspring of persons with Huntington's disease have a 50% risk of disease development.

235 Continuous and excessive involuntary movements will occur. Onset of the disease occurs between the ages of 30 and 50 years. Offspring have a 50% risk of developing the disease because of the autosomal dominant transmission. If the patient has the gene, eventually the symptoms of the disease will occur. There is no cure for Huntington's disease currently, but there is treatment. A positive genetic testing does not tell the patient at what age symptoms of the disease will appear. Diagnosis is often made after the affected person has had children.

*******For the patient with multiple sclerosis (MS), who has a new prescription for diazepam (Valium), which teaching points would the nurse provide? Select all that apply. 1 Avoid contact with large crowds. 2 Do not stop the medication abruptly. 3 Monitor your BP regularly. 4 Avoid driving while on the medication. 5 Avoid alcohol intake with the medication.

245 Diazepam is a muscle relaxant. Patients on diazepam should avoid driving and any such activities requiring the patient to be alert because of the sedative effects of the drug. They should not stop the drug abruptly without consulting the health care provider. Do not take the medication along with alcohol because alcohol can potentiate the drug's effect. Monitoring BP is a general health care measure and is not specific to diazepam. Because the drug has no effect on the immune system, avoiding crowds is not necessary.

For the patient with Parkinson's disease who is taking levodopa with carbidopa (Sinemet), the nurse would monitor the potential development of which side effect(s)? Select all that apply. 1 Dizziness 2 Dyskinesia 3 Severe headache 4 Involuntary eyelid movements 5 Severe nausea and vomiting

245 Sinemet is a combination of levodopa and carbidopa and is prescribed to patients suffering from parkinsonism. The drug has few side effects. These side effects include dyskinesia due to increased dopamine availability. Severe nausea and vomiting are other important side effects because the dopaminergic pathway is the major pathway involved in emesis. Increased dopamine levels in the body may trigger the sensation of nausea and vomiting. Involuntary eyelid movements are due to the increased levels of the neurotransmitter dopamine in the body. Dizziness or fainting, due to orthostatic hypotension, is a side effect of the drug bromocriptine. A severe headache is also a side effect of bromocriptine.

*******Which instructions would the nurse provide the patient who has a history of focal seizures, controlled with phenytoin (Dilantin), and mild gingival hyperplasia? Select all that apply. 1 The gingival tissue requires a surgical repair. 2 Regular tooth brushing can limit hyperplasia. 3 Gingival hyperplasia is not related to phenytoin. 4 Consult your provider to change the medication. 5 Regular flossing can control gingival tissue growth.

25 Gingival hyperplasia is a common side effect of phenytoin. The nurse should instruct the patient to maintain good dental hygiene with regular tooth brushing and flossing. Regular flossing not only helps to maintain good dental hygiene but also helps control gingival tissue growth. Similarly, regular brushing, besides being generally good for dental health, also helps to limit gingival hyperplasia. Mild gingival hyperplasia does not require a change in their medication. Required surgical intervention occurs only if the gingival hyperplasia were extensive, which is not the case with this patient.

Which conditions are primary causes of heart failure? Select all that apply. 1 Anemia 2 Myocarditis 3 Paget's disease 4 Pulmonary embolism 5 Coronary artery disease

25 Myocarditis and coronary artery disease are primary causes of heart failure. Anemia, Paget's disease, and pulmonary embolism are precipitating causes of heart failure.

A patient with a history of left-sided heart failure arrives in the emergency department reporting extreme shortness of breath and a persistent cough with pink, frothy sputum. On auscultation of the heart, the nurse notes an S3 gallop. Which condition is a likely cause of these symptoms? 1 Pneumonia 2 Asthma attack 3 Pulmonary edema 4 Myocardial infarction

3 Extreme shortness of breath and a persistent cough with pink, frothy sputum are symptoms of pulmonary edema. Pink, frothy sputum and an S3 gallop are not symptoms of pneumonia, an asthma attack, or myocardial infarction.

If a patient has Parkinson's disease, which patient reaction would the nurse expect when performing a pull test by standing behind the patient and giving a tug backward on the patient's shoulders? 1 Loses balance and sits down 2 Loses balance and falls forward 3 Loses balance and falls backward 4 Loses balance and becomes unconscious

3 In a pull test, when the examiner stands behind the patient and gives a tug backward on the shoulder, the patient loses balance and falls backward. This reaction indicates postural instability, a common feature in Parkinson's disease. Sitting down, falling forward, or becoming unconscious after losing balance is not indicative of postural instability related to Parkinson's disease.

******A nurse is caring for a patient with pleural effusion who has S3 and S4 heart sounds, crackles, and an increased heart rate. Which condition is likely affecting the patient? 1 Cor pulmonale 2 Pulmonary embolism 3 Left-sided heart failure 4 Right-sided heart failure

3 Manifestations of left-sided heart failure include pleural effusion, S3 and S4 heart sounds, crackles, and an increased heart rate. These symptoms indicate a low cardiac output. Cor pulmonale is the dilation of the right ventricle caused by pulmonary diseases. It manifests as right heart failure. Right-sided heart failure causes edema, murmurs, and jugular vein distention. Pulmonary embolism manifests as chest pain, tachycardia, anxiety, and dizziness.

******The nurse encourages the patient diagnosed with chronic heart failure to obtain physical and emotional rest. Which rationale would the nurse give for this recommendation? 1 To relieve dyspnea and fatigue 2 To increase the oxygen saturation of the blood 3 To decrease the need for additional oxygen 4 To involve the patient in cardiac rehabilitation

3 Physical and emotional activities may cause additional utilization of oxygen. Therefore the patient is advised to take rest to conserve energy and prevent additional use of oxygen. The administration of oxygen relieves dyspnea and fatigue. Taking physical and emotional rest does not affect the oxygen saturation of the blood. Asking the patient to take rest may help conserve energy but would not motivate the patient to participate in cardiac rehabilitation.

Which treatment option would the nurse associate with the patient who was received in the emergency department in an unconscious state, who has a routine prescription of gabapentin (Neurontin) for a history of epilepsy, and who is experiencing recurring seizures in rapid succession? 1 Administer dextrose (D5W) IV 2 Administer saline (NS 0.9%) IV 3 Administer diazepam (Valium) IV 4 Administer gabapentin (Neurontin) IV

3 Seizures that reoccur in rapid succession without the patient regaining consciousness are a characteristic feature of status epilepticus. It is a serious complication of epilepsy and occurs with any type of seizure. The most commonly used drug to treat status epilepticus is diazepam. Administer saline to patients with severe dehydration and electrolyte imbalance. Administer dextrose if the patient has seizures due to hypoglycemia. Gabapentin treats generalized seizures.

Which intervention would the nurse implement when a patient experiences a generalized tonic-clonic seizure? 1 Restrain the patient's arms and legs. 2 Control head movements of the patient. 3 Protect the patient's head and extremities. 4 Insert a tongue blade between the patient's teeth.

3 Staying with the patient to provide protection of the head and extremities is the most important nursing care activity for a patient experiencing a generalized tonic/clonic seizure. Attempting to restrain or control the jerking movement of the head and extremities during a seizure may cause further injury and even fracture bones. Do not restrain or control body parts. Use of a tongue blade is not acceptable in current practice because insertion once the seizure begins is difficult and the patient may bite through the tongue blade and aspirate.

Which seizure phase would the nurse identify when a patient with systemic lupus erythematosus presents to the emergency department with warm skin, pallor, lethargy, and an altered level of consciousness? 1 Tonic phase 2 Clonic phase 3 Postictal phase 4 Hypertonic phase

3 Systemic lupus erythematosus can lead to tonic-clonic seizures. Warm skin and pallor are the clinical signs of tonic-clonic seizures. Tonic-clonic seizures progress through several phases. Lethargy and altered level of consciousness occur in the postictal phase, so the probable phase of this patient's stroke is the postictal phase. In the tonic phase, continuous muscle contraction occurs. Rigidity and relaxation in rapid succession occur in the clonic phase. Extreme muscle rigidity occurs in the hypertonic phase, which lasts for 5 to 15 seconds.

While the nurse is administering furosemide via IV push (IVP), a patient becomes unresponsive. The patient's electrocardiogram (ECG) tracing shows the following. Which action would the nurse perform first? VTACH 1 Cardiovert. 2 Defibrillat. 3 Check for a pulse. 4 Administer oxygen.

3 The ECG tracing is ventricular tachycardia (VT). Ventricular tachycardia can either be with a pulse or pulseless. The treatment algorithm depends on whether the patient has a pulse. Therefore checking for a pulse is a priority. If the patient has a pulse, cardioversion and/or drug therapy is the priority. If the patient does not have a pulse, defibrillation is the priority. Oxygen may be administered, but it is not a priority.

For the patient with multiple sclerosis, which action would the nurse classify as a priority intervention when developing the patient's plan of care? 1 Refer the patient for genetic counseling. 2 Teach the patient about medications used during acute exacerbations. 3 Assist the patient in identifying the factors that precipitate exacerbations. 4 Instruct the patient in the proper technique for self-administration of an enema.

3 The cause of multiple sclerosis is unknown, although fatigue, stress, or events such as pregnancy or acute illness can bring on an exacerbation. Identifying and avoiding such activities or factors may prevent exacerbations. Multiple sclerosis does not have a genetic link. Teaching the patient about medications and the proper technique for the self-administration of an enema is important but not as high of a priority as preventing exacerbations of the disease and complications.

The electrocardiogram (ECG) monitor of a patient in the cardiac care unit after myocardial infarction (MI) indicates ventricular fibrillation. Which action would the nurse take immediately? 1 Perform synchronized cardioversion. 2 Administer IV amiodarone. 3 Perform cardiopulmonary resuscitation (CPR). 4 Prepare for insertion of a temporary transvenous pacemaker.

3 Treatment consists of immediate initiation of CPR and advanced cardiac life support (ACLS) with the use of defibrillation and definitive drug therapy (e.g., epinephrine, vasopressin). There should be no delay in using a defibrillator once available. Amiodarone, cardioversion, and temporary pacemakers are not used to treat ventricular fibrillation.

A patient in asystole is likely to receive which drug treatment? 1 Digoxin 2 Lidocaine 3 Epinephrine 4 β-adrenergic blockers

3 Treatment of asystole consists of cardiopulmonary resuscitation (CPR) with initiation of advanced cardiac life support (ACLS) measures. These include definitive drug therapy with epinephrine and intubation. Digoxin is used for ventricular rate control. Lidocaine is used for premature ventricular contractions (PVCs). β-adrenergic blockers are used to slow the heart rate.

Which classic symptom of amyotrophic lateral sclerosis (ALS) would the nurse expect to identify when performing an assessment? 1 Dysuria 2 Dyspnea 3 Dysphagia 4 Dysreflexia

3 Weakness of the muscles of the legs that progresses to weakness in the upper extremities, dysarthria (difficulty in speech), and dysphagia (difficulty swallowing) are all classic symptoms of ALS. Although dyspnea and dysuria may be present in later stages of ALS, they are not classic symptoms of the disease. Dysreflexia occurs in patients with spinal cord injuries and is a life-threatening, uninhibited response of the nervous system to a noxious stimulus and not applicable to ALS.

********Which information would the nurse provide a patient with multiple sclerosis who begins treatment with β-interferon? Select all that apply. 1 Monitor vital signs on a regular basis. 2 Rotate injection sites with each dose. 3 Do not drink grape juice or eat grapes. 4 Know that flulike symptoms are common. 5 Wear sunscreen while exposed to sunlight.

345 Patients on β-interferon should wear sunscreen when exposed to sunlight because the drug may cause photosensitivity. Rotate the injection sites with each dose to prevent lipodystrophy. The nurse should let the patient know that flulike symptoms are common with β-interferon. These symptoms usually subside on their own; if they do not, treat with nonsteroidal antiinflammatory drugs (NSAIDs). The drug does not interact with grape juice; therefore, consuming grape juice and grapes is permissible. Monitoring vital signs is not a specific teaching related to the drug.

When performing a physical examination of a patient with Parkinson's disease, which associated clinical manifestations would the nurse likely identify? Select all that apply. 1 Nystagmus 2 Patchy blindness 3 Drooling of saliva 4 Decreased arm swing 5 Shuffling, propulsive gait

345 The patient may manifest drooling of saliva, shuffling, propulsive gait, and decreased arm swing. These symptoms are due to the combination of tremors, rigidity of muscles, and bradykinesia. Parkinson's disease does not have clinical manifestations of patchy blindness (migraine headaches) or nystagmus.

When evaluating the presence of an initial symptom of Parkinson's disease, which clinical manifestation would the nurse evaluate? 1 Akinesia 2 Aspiration 3 Forgetfulness 4 Pill-rolling tremors

4 Early symptoms of Parkinson's disease include coarse resting tremors of the fingers and thumb, also known as pill-rolling movements. Akinesia (complete or partial loss of muscle movement), aspiration, and mental deterioration occur later in the disease process.

For which major complication would the nurse monitor development in a patient experiencing a myasthenic crisis? 1 Speech alteration 2 Difficulty chewing 3 Impaired facial mobility 4 Respiratory insufficiency

4 Myasthenic crisis is the acute exacerbation of myasthenia gravis and is a life-threatening condition occurring when the muscles that control breathing and swallowing become too weak to perform their functions. The clinical manifestations of myasthenia gravis include speech alteration due to muscle weakness related to speech. However, this is not a major complication associated with myasthenic crisis. Difficulty in chewing is due to the weakness of muscles related to chewing but is not a major complication associated with myasthenic crisis. Impaired facial mobility and expression are the clinical manifestations of myasthenia gravis due to the weakness of facial muscles but are not a major complication associated with myasthenic crisis.

A patient is scheduled to receive IV adenosine. What action should the nurse take while administering the medication? 1 Observe the patient for pallor and hypotension. 2 Give the dose over 1 to 2 minutes and follow with a 20 mL normal saline flush. 3 Monitor the patient carefully for 10 minutes, the length of the drug's half-life. 4 Use an injection site as close to the heart as possible.

4 The drug's half-life is very short. Therefore it is imperative that it be given via an IV site as close as possible to the heart. The nurse should monitor the patient for flushing, dizziness, chest pain, or palpitations. Adenosine has a very short half-life (less than 10 seconds) and must be given rapidly, within one to two seconds, followed immediately by 20 mL of normal saline bolus flush.

Which finding would the nurse monitor in the patient who has left-sided heart failure? 1 Pedal edema 2 Hepatomegaly 3 Splenomegaly 4 Pulmonary congestion

4 The most common form of heart failure is left-sided heart failure. It results from left ventricular dysfunction. This prevents normal, forward blood flow and causes blood to back up into the left atrium and pulmonary veins. There would be fluid leakage from the pulmonary capillary bed into the interstitium and then the alveoli; this manifests as pulmonary congestion and edema. Right-sided heart failure, which occurs when the right ventricle fails to contract effectively, causes pedal edema, hepatomegaly, and splenomegaly.

Which degenerative neurologic disorder exhibits a deficiency of ϒ-aminobutyric acid (GABA) and acetylcholine? 1 Myasthenia gravis 2 Parkinson's disease 3 Lou Gehrig's disease 4 Huntington's disease

4 The pathologic process of Huntington's disease involves a deficiency of the neurotransmitters GABA and acetylcholine, which leads to the excessive release of dopamine. Myasthenia gravis occurs due to a decrease in the acetylcholine receptors because of an autoimmune process. In this disease, there is no deficiency of the neurotransmitters. The pathologic process of Parkinson's disease involves degeneration of dopamine-producing neurons, which leads to a deficiency of dopamine release. Lou Gehrig's disease involves degeneration of motor neurons in the brain and spinal cord and is not related to the deficiency of neurotransmitters.

When assessing a patient for the presence of petit mal, or absence, seizures, which classic sign would the nurse associate with this disorder? 1 Dizziness 2 Intense anxiety 3 Stiffening of the body 4 Vacant facial expression

4 The patient experiencing a petit mal, or absence, seizure displays a sudden vacant look and usually stares straight ahead. This type of seizure often goes unnoticed by the patient and others. Dizziness and intense anxiety are not commonly associated with petit mal seizures. Stiffening of the body is the tonic phase associated with a tonic-clonic seizure, not an absence seizure.

Which seizure disorder typically occurs in children and rarely continues beyond adolescence? 1 Focal seizures 2 Tonic-clonic seizures 3 Psychogenic seizures 4 Typical absence seizures

4 Typical absence seizures occur typically in children and rarely continuing beyond adolescence. A psychogenic seizure may be mistaken for epilepsy. A tonic-clonic seizure is the most common generalized seizure. Focal seizures are a major class of seizures. Psychogenic, tonic-clonic, and focal seizures can occur in patients of all ages.

_______________ is the preferred drug for absence and myoclonic seizures.

Clonazepam

********A patient is diagnosed with pulseless ventricular tachycardia. In which order would the nurse perform the steps of defibrillation?

Defibrillation is the treatment of choice for pulseless ventricular tachycardia. The nurse would first turn the defibrillator on and select the proper energy level, then check to see that the synchronizer switch is turned off. The nurse then would apply conductive materials to the chest and charge the defibrillator using the button on the defibrillator or the paddles. The nurse would then position the paddles firmly on the chest wall over the conductive material. The nurse would then check to see that everyone is "all clear." Finally, the nurse would deliver the charge by depressing buttons on both paddles simultaneously.

_____________ is the primary drug used for absence and myoclonic seizures.

Ethosuximide

For the patient taken to the hospital after a seizure, which characteristic pattern reported by the patient's caregiver would the nurse associate with those of a tonic-clonic seizure? 1 Stiffening of the body for 20 seconds, followed by jerking of the extremities for 40 seconds 2 Jerking of the extremities for 20 seconds, followed by stiffening of the body for 40 seconds 3 Stiffening of the body for 30 seconds, followed by jerking of the extremities for 10 seconds 4 Jerking of the extremities for 20 seconds, followed by stiffening of the body for 10 seconds

Loss of consciousness, followed by stiffening of the body for 20 seconds (10 to 20 seconds) and jerking of the extremities for 40 seconds (30 to 40 seconds) are features of tonic-clonic seizures. Jerking of the extremities for 20 seconds, followed by stiffening of the body for 40 seconds may not be associated with tonic-clonic seizures. Tonic-clonic seizures do not include stiffening of the body for 30 seconds, followed by jerking of the extremities for 10 seconds. Similarly, jerking of the extremities for 20 seconds, followed by stiffening of the body for 10 seconds is not with a characteristic of tonic-clonic seizures.

What is lidocaine used for?

PVCs

_____________ is the primary drug of choice for tonic-clonic seizures.

Phenytoin

The ____________ phase has a sensory warning for the seizure.

aural

. ____________ is an alternative drug for tonic-clonic, absence, and myoclonic seizures.

gabapentin

Multiple sclerosis usually exhibits itself on one side more than the other. Therefore the ___________ is unsteady, so there is an increase in the patient's fall risks. Acute confusion may be a manifestation experienced by some patients later in the multiple sclerosis disease process. Deficient fluid volume and ineffective thermoregulation are not characteristics of multiple sclerosis. Visual disturbances and muscle spasticity may also contribute to the patient's potential risk for injury.

gait

The ______________ phase includes a full seizure.

ictal

Amyotrophic lateral sclerosis is a rare, progressive neurologic disorder characterized by loss of motor neurons. Characteristics of the disease are _________ weakness, difficulty in articulating words (_________), and difficulty in swallowing (__________). The symptoms are due to denervation of the muscles and lack of stimulation and use. Twisting movements of the face and involuntary movements of the body do not occur in amyotrophic lateral sclerosis.

limb, dysarthria, dysphagia

Patients on β-interferon should wear sunscreen when exposed to sunlight because the drug may cause ________________. Rotate the injection sites with each dose to prevent ______________. The nurse should let the patient know that __________ symptoms are common with β-interferon. These symptoms usually subside on their own; if they do not, treat with nonsteroidal antiinflammatory drugs (NSAIDs). The drug does not interact with grape juice; therefore, consuming grape juice and grapes is permissible. Monitoring vital signs is not a specific teaching related to the drug.

photosensitivity lipodystrophy flulike

The _____________ phase is the recovery period after the seizure.

postictal

The _______________ phase involves signs that precede a seizure

prodromal