Exam 3 Review

ANS: B Feedback: Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.

A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)

D. Absence This is an absence seizure and is most common in children. The hallmark of it is staring that appears to be like a daydreaming state. It is very short and the post ictus stage of this type of seizure is immediate.

A 7-year-old male patient is being evaluated for seizures. While in the child's room talking with the child's parents, you notice that the child appears to be daydreaming. You time this event to be 10 seconds. After 10 seconds, the child appropriately responds and doesn't recall the event. This is known as what type of seizure? A. Focal Impaired Awareness (complex partial) B. Atonic C. Tonic-clonic D. Absence

B. Assess the client's gait for steadiness.

A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following? A. Administer PRN haloperidol (Haldol) to decrease the need to walk.  B. Assess the client's gait for steadiness. C. Restrain the client in a geriatric chair.  D. Administer PRN lorazepam (Ativan) to provide sedation.

Ans: A Feedback: To prevent complications, the patient is placed in the side-lying position to facilitate drainage of oral secretions. Suctioning is performed, if needed, to maintain a patent airway and prevent aspiration. None of the other listed actions promotes safety during the immediate recovery period.

A hospital patient has experienced a seizure. In the immediate recovery period, what action best protects the patients safety? A) Place the patient in a side-lying position. B) Pad the patients bed rails. C) Administer antianxiety medications as ordered. D) Reassure the patient and family members.

ANS: A, B, C Clients at risk for secondary seizures include those with a brain lesion from a tumor or trauma, and those who are experiencing a metabolic disorder, acute alcohol withdrawal, electrolyte disturbances, and high fever. Clients with a history of stroke, heart disease, and substance abuse are also at risk. Clients with multiple sclerosis or chronic obstructive pulmonary disease are not at risk for secondary seizures.

A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) a. A 26-year-old woman with a left temporal brain tumor b. A 38-year-old male client in an alcohol withdrawal program c. A 42-year-old football player with a traumatic brain injury d. A 66-year-old female client with multiple sclerosis e. A 72-year-old man with chronic obstructive pulmonary disease

ANS: C Keeping a headache diary to try to identify triggers to migraines can be helpful when a patient is trying to prevent them and is the first step in managing headaches. Prochlorperazine is an antiemetic and does not prevent or abort migraine headaches. Prophylactic medications are used when headaches are more frequent. To prevent medication-overuse headache, abortive medications should not be used more than 1 to 2 days at a time.

A patient who has occasional migraine headaches tells a nurse that the abortive medication works well, but she would like to do more to prevent the occurrence of these headaches. The nurse will suggest that the patient: a. ask the provider about an adjunct medication, such as prochlorperazine. b. discuss the use of prophylactic medications with the provider. c. keep a headache diary to help determine possible triggers. d. take the abortive medication regularly instead of PRN.

Correct: B,D,E Manifestations of phenytoin toxicity can occur when plasma levels are higher than 20 mcg/mL. Nystagmus (back-and-forth movement of the eyes) is a common indicator of toxicity, as are ataxia (staggering gait), diplopia (double vision), sedation, and cognitive impairment. Hirsutism (excess hair growth in unusual places) and gingival hyperplasia (swollen, tender, bleeding gums) are adverse effects of phenytoin.

The nurse suspects that a female patient is experiencing phenytoin toxicity if which manifestation is noted? (Select all that apply.) A) The patient complains of excessive facial hair growth. B) The patient is walking with a staggering gait. C) The patient's gums are swollen, tender, and bleed easily. D) The patient complains of double vision. E) The nurse observes rapid back-and-forth movement of the patient's eyes

b. salted cashews Nuts contain tyramine, which can trigger migraine headaches.

A nurse in a clinic is caring for a client who has frequent migraine headaches. The client asks about foods that can cause headaches. The nurse should recommend that the client avoid which of the following foods? a. baked salmon b. salted cashews c. frozen strawberries d. fresh asparagus

c. "I should expect facial flushing when I take this med"

A nurse in a clinic is teaching a client who has a history of migraine HAs about a new prescription for zolmitriptan. Which of the following statements by the client indicates understanding of this teaching? a. "this med will relieve my symptoms by causing my blood vessels to dilate" b. "I should take this med daily to prevent the HA from occurring" c. "I should expect facial flushing when I take this med" d. "This med will lower my sensitivity to food triggers"

•B. Pill‑rolling tremor of the fingers •C. Shuffling gait •D. Drooling •F. Lack of facial expression Rationale: The client who has PD can manifest pill‑rolling tremors of the fingers due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. The client who has PD can manifest shuffling gaitbecause of overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult. The client who has PD can manifest drooling because of overstimulation of the basal ganglia by acetylcholine,making the controlled movement of swallowing secretions difficult. The client who has PD can manifest a lack of facial expressions due to overstimulation of the basal ganglia by acetylcholine, making controlled movement difficult.

A nurse is assessing a client for manifestations of Parkinson's disease.Which of the following are expected findings? (Select all that apply.) A. Decreased vision B. Pill‑rolling tremor of the fingers C. Shuffling gait D. Drooling E. Bilateral ankle edema F. Lack of facial expression

B. Rational: Fruity odor of breath is a manifestation of elevated ketone levels that lead to metabolic acidosis. C. Rational: Abdominal pain is a GI manifestation of increased ketones and acidosis. D. Rational: Kussmaul respirations are an attempt to excrete carbon dioxide and acid when in metabolic acidosis. E. Rational: Metabolic acidosis is caused by glucose, protein, and fat breakdown, which produces ketones.

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

B. Implement droplet precautions. When using the urgent vs. non-urgent approach to care, the nurse determines the priority action is to initiate droplet precautions when meningitis is suspected to prevent spread of the disease to others.

A nurse is assessing a client who reports severe headache and a stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first? A. Administer antibiotics. B. Implement droplet precautions. C. Initiate IV access. D. Decrease bright lights.

A. Correct: The nurse should place the client in supine position when assessing for Brudzinski's sign. B. Incorrect: The nurse should flex the client's hip and knee when assessing for Kernig's sign but not Brudzinski's sign. C. Correct: The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck. D. Correct: The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign; it is a positive if the client reports pain. E. Incorrect: The nurse should straighten the client's flexed leg at the knee when assessing for Kernig's sign but not Brudzinski's sign.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply.) A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee

A. The nurse should place the client in supine position when assessing for Brudzinski's sign. C. The nurse should place her hands behind the client's neck when assessing for Brudzinski's sign, in order to flex the client's neck. D. The nurse should bend the client's head toward the chest when assessing for Brudzinski's sign.

A nurse is assessing for the presence of Brudzinski's sign in a client who has suspected meningitis. Which of the following actions should the nurse take when performing this technique? (Select all that apply.) A. Place client in supine position B. Flex client's hip and knee C. Place hands behind the client's neck D. Bend client's head toward chest E. Straighten the client's flexed leg at the knee

C. Rational: Blurred vision is a manifestation associated with cataracts. D. Rational: White pupils are a manifestation associated with cataracts.

A nurse is caring for a client who has a new diagnosis of cataracts. Which of the following manifestations should the nurse expect? (Select all that apply.) A. Eye pain B. Floating spots C. Blurred vision D. White pupils E. Bilateral red reflexes

B. Rational: Genetic predisposition is a risk factor associated with glaucoma. C. Rational:Hypertension is a risk factor associated with glaucoma. D. Rational: Age is a risk factor associated with glaucoma. E. : Diabetes mellitus is a risk factor associated with glaucoma.

A nurse is caring for a male older adult client who has a new diagnosis of glaucoma. Which of the following should the nurse recognize as risk factors associated with this disease? (Select all that apply.) A. Gender B. Genetic predisposition C. Hypertension D. Age E. Diabetes mellitus

B. Open-angle glaucoma Rational: This is a manifestation of open-angle glaucoma. A gradual loss of peripheral vision is a manifestation associated with this diagnosis.

A nurse is caring for an older adult client who has diabetes mellitus and reports a gradual loss of peripheral vision. The nurse should recognize this as a manifestation of which of the following diseases? A. Cataracts B. Open-angle glaucoma C. Macular degeneration D. Angle-closure glaucoma

B, E Rationale: The nurse should record the client's diet and fluid intake daily to assess for dietary needs and to maintain adequate nutrition and hydration. The nurse should offer nutritional supplements between meals to maintain the client's weight.

A nurse is developing a plan of care for the nutritional needs of a client who has stage IV Parkinson's disease. Which actions shouldthe nurse include in the plan of care? (Select all that apply.) A. Provide three large balanced meals daily. B. Record diet and fluid intake daily. C. Document weight every other week. D. Place the client in Sims position to eat. E. Offer nutritional supplements between meals.

ACDE

A nurse is making a home visit to a client with AD. The client partner states that the client is disoriented to time and place, is unsteady on feet, and has history of wandering. Which safety measures should nurse review with the partner A.Remove Floor Rugs B.Have door locks that can be easily opened C.Provide increased lighting in stair well D.Install handrail in bathroom E.Place mattress on floor

d. "do you have the same S/S each time the HA occurs?" Clients who have aura type migraines typically have the same S/S each time the HA occurs

A nurse is obtaining a health history from a client who is being evaluated for the cause of frequent headaches. Which of the following questions should the nurse ask to identify the aura type of migraine HAs? a. "do the headaches occur multiple times each day?" b. "is your HA accompanied by profuse facial sweating?" c. "does your HA occur on one side of your head?" d. "do you have the same S/S each time the HA occurs?"

A. Incorrect: The nurse should plan to monitor for tachycardia when a client has meningitis. B. Correct: The nurse should provide an emesis basin at the bedside because the client who has meningitis may have nausea and vomiting. C. Correct: The nurse should plan to administer antipyretic medication for fever to a client who has meningitis. D. Correct: The nurse should perform a skin assessment to determine whether the client has a red macular rash associated with meningococcal meningitis. E. Incorrect: The nurse should elevate the head of the client's bed 30° to promote venous drainage from the head and prevent increased intracranial pressure (ICP).

A nurse is planning care for a client who has bacterial meningitis. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Monitor for bradycardia. B. Provide an emesis basin at the bedside. C. Administer antipyretic medication. D. Perform a skin assessment. E. Keep the head of the bed flat.

A. The client is at risk for seizures due to possible increased ICP. Therefore, the nurse should implement seizure precautions to reduce the client's risk for injury D. The nurse should turn off room lights and the television because they can increase neuron stimulation and cause a seizure when a client is at risk for increased ICP. E. The nurse should monitor for impaired extraocular movements because this finding can indicate increased ICP.

A nurse is planning care for a client who has meningitis and is at risk for increased intracranial pressure (ICP). Which of the following actions should the nurse plan to take? (Select all that apply.) A. Implement Seizure precautions. B. Perform neurological checks four times a day. C. Administer morphine for the report of neck and generalized pain. D. Turn off room lights and television. E. Monitor for impaired extraocular movements. F. Encourage the client to cough frequently

B. Administer insulin when breakfast arrives. Rational: Administer insulin aspart when breakfast arrives to avoid a hypoglycemic episode. Insulin aspart is rapid-acting, and should be administered 5 to 10 min before breakfast.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse implement? A. Check blood glucose immediately after breakfast. B. Administer insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

C. Draw up and administer regular and glargine insulin in separate syringes. Rational: Administer each insulin as a separate injection. These insulins are not compatible and should not be drawn up in the same syringe.

A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. E. Include omega-3 fatty acids in the diet.

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.) A. Eat less meat and processed foods. B. Decrease intake of saturated fats. C. Increase daily fiber intake. D. Limit saturated fat intake to 15% of daily caloric intake. E. Include omega-3 fatty acids in the diet.

A. Rise slowly when standing. Rationale: Orthostatic hypotension is a common adverse effect of bromocriptine, a dopamine receptor agonist. Therefore, rising slowly when standing up will decrease the risk of dizziness and lightheadedness

A nurse is reinforcing teaching with a client who has Parkinson's disease and has a new prescriptionfor bromocriptine. Which of thefollowing instructions should the nurse include in the teaching? A. Rise slowly when standing. B. Expect urine to becomedark‑colored. C. Avoid foods containing tyramine. D. Report any skin discoloration.

C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes. C. Perform nail care after bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

ANS: A, D, F Oxygen and suctioning equipment with an airway must be readily available. The bed rails should be up at all times while the client is in the bed to prevent injury from a fall if the client has a seizure. If the client does not have an IV access, insert a saline lock, especially for those clients who are at significant risk for generalized tonic-clonic seizures. The saline lock provides ready access if IV drug therapy must be given to stop the seizure. Padded tongue blades may pose a danger to the client during a seizure and should not be used. Dietary restrictions and strict bedrest are not interventions associated with epilepsy. The client should be encouraged to eat a well-balanced diet and ambulate while in the hospital.

A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.

b. Nystagmus or confusion Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech. An aura, focal seizure, abdominal pain or cramping, irregular pulse, or palpitations are not associated with phenytoin toxicity.

A patient has been receiving scheduled doses of phenytoin (Dilantin) and begins to experience diplopia. Which additional findings would the nurse expect? a. An aura or focal seizure b. Nystagmus or confusion c. Abdominal pain or cramping d. Irregular pulse or palpitations

B Phenytoin level is 10 to 20 mcg/mL. The patient's level is low; therefore, the patient is at risk for seizures. The nurse should initiate seizure precautions. Remember a patient being under medicated is a trigger for developing a seizure.

A patient with a history of epilepsy is taking Phenytoin. The patient's morning labs are back, and the patient's Phenytoin level is 7 mcg/mL. Based on this finding, the nurse will? A. Assess the patient for a rash B. Initiate seizure precautions C. Hold the next dose of Phenytoin D. Continue to monitor the patient

d. If I am nauseated, I will not take my epilepsy medication. Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.

ADE

Nurse who is caring for a client who has Alzheimers disease. A family member of client ask nurse about risk factors. Which of the following should be included in the response: A. Exposure to metal waste products B.Long term estrogen hormone therapy C.Sustained use of Vitamin E D.Previous head injury E.History of herpes infection

3. A positive Kernig's sign, client unable to extend leg when lying flat, and nuchal rigidity, stiff neck, are signs of bacterial meningitis, occurring because the meninges surrounding the brain and spinal column are irritated

The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestations would support the diagnosis of bacterial meningitis? 1. Positive Babinski's sign and peripheral paresthesia 2. Negative Chvostek's sign and facial tingling 3. Positive Kernig's sign and nuchal rigidity. 4. Negative Trousseau's sign and nystagmus.

Apply a moisturizing lotion to dry feet, but not between the toes

The nurse is assisting with preparing a teaching plan for the client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan of care? 1. Soak feet in hot water 2. Avoid using soap to wash the feet 3. Apply a moisturizing lotion to dry feet, but not between the toes 4. Always have a podiatrist cut your toenails; never cut them yourself

B. "I should call 911 if breathing stops during the seizure." Caregivers do not need to call an ambulance or send a person to the hospital after a single seizure unless the seizure is prolonged, another seizure immediately follows, or extensive injury has occurred. Altered breathing is a clinical manifestation of a tonic-clonic seizure. Contact emergency medical services (or call 911) if breathing stops for more than 30 seconds. No objects (e.g., oral airway, padded tongue blade) should be placed in the mouth. Lethargy is common in the postictal phase of a seizure. Jerking of the extremities occurs during the clonic phase of a tonic-clonic seizure. The clonic phase may last 30 to 40 seconds.

The nurse provides information to the caregiver of a 68-year-old man with epilepsy who has tonic-clonic seizures. Which statement, if made by the caregiver, requires further teaching? A. "It is normal for a person to be sleepy after a seizure." B. "I should call 911 if breathing stops during the seizure." C. "The jerking movements may last for 30 to 40 seconds." D. "Objects should not be placed in the mouth during a seizure."

A. IV dextrose solution This patient's seizure is caused by low blood glucose, so IV dextrose solution should be given first to stop the seizure. IV diazepam, IV phenytoin, and oral carbamazepine would be used to treat seizures from other causes such as head trauma, drugs, and infections.

The patient with type 1 diabetes mellitus with hypoglycemia is having a seizure. Which medication should the nurse anticipate administering to stop the seizure? A. IV dextrose solution B. IV diazepam (Valium) C. IV phenytoin (Dilantin) D. Oral carbamazepine (Tegretol)

Low-frequency unilateral sensorineural hearing impairment.

What is typical of the audiometry results for Meniere disease?

B. The seizure involved lip smacking and repetitive movements. 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.

Which characteristic of a patient's recent seizure is consistent with a focal seizure? A. The patient lost consciousness during the seizure. Incorrect B. The seizure involved lip smacking and repetitive movements. C. The patient fell to the ground and became stiff for 20 seconds. D. The etiology of the seizure involved both sides of the patient's brain.

4. Droplet cautions are respiratory precautions use for organisms that have limited span transmission. Precautions including staying at least 4 feet away from the client or wearing a standard isolation mask and gloves when coming in close contact with the client. Clients are in isolation for 24 to 48 hours after initiation of antibiotics

Which type of precautions should the nurse implement for the client diagnosed with septic meningitis? 1. Standard precautions 2. Airborne precautions 3. Contact precautions 4. Droplet precautions

Ans: B. Feedback: The patient should avoid all alcohol because it can lead to a seizure. Hormone shifts (menstrual cycle, ovulation, pregnancy) sleep deprivation, and dehydration can lead to a seizure.

You're educating a 25-year-old female about possible triggers for seizures. Which statement requires you to re-educate the patient about the triggers? A. "I'm at risk for seizure activity during my menstrual cycle." B. "I will limit my alcohol intake to 2 glasses of wine per day." C. "It's important I get plenty of sleep." D. "I will be sure to stay hydrated, especially during hot weather."

C. Based on the findings during the seizure the patient experienced a tonic-clonic seizure. In the post ictus stage (after the seizure) the patient is expected to be sleepy (very tired), have soreness, and a headache. The nurse should let the patient sleep.

Your patient has entered the post ictus stage for seizures. The patient's seizure presented with an aura followed by body stiffening and then recurrent jerking. The patient had incontinence and bleeding in the mouth from injury to the tongue. What is an expected finding in this stage based on the type of seizure this patient experienced? A. Crying and anxiety B. Immediate return to baseline behavior C. Sleepy, headache, and soreness D. Unconsciousness