Eye, ear and neurological

596. A client with a seizure disorder is being admitted to the hospital. Which should the nurse plan to implement for this client? Select all that apply. 1. Pad the bed's side rails. 2. Place an airway at the bedside. 3. Place oxygen equipment at the bedside. 4. Place suction equipment at the bedside. 5. Tape a padded tongue blade to the wall at the head of the bed.

1, 2, 3, 4 Rationale: The nurse should plan seizure precautions for a client with a seizure disorder. The precautions include padded side rails and an airway, and oxygen and suction equipment at the bedside. Attempts to force a padded tongue blade between clenched teeth may result in injury to the teeth and mouth; therefore a padded tongue blade is not placed at the bedside.

571. The nurse is preparing to reinforce a teaching plan for a client who is undergoing cataract extraction with intraocular implant. Which home care measures should the nurse include in the plan? Select all that apply. 1. To avoid activities that require bending over 2. To contact the surgeon if eye scratchiness occurs 3. To place an eye shield on the surgical eye at bedtime 4. That episodes of sudden severe pain in the eye are expected 5. To contact the surgeon if a decrease in visual acuity occurs 6. To take acetaminophen (Tylenol) for minor eye discomfort

571. 1, 3, 5, 6 Rationale: After eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and is usually relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse would also instruct the client to notify the surgeon of purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure such as bending over.

572. The nurse is assisting in developing a teaching plan for the client with glaucoma. Which instruction should the nurse suggest to include in the plan of care? 1. Decrease the amount of salt in the diet. 2. Decrease fluid intake to control the intraocular pressure. 3. Avoid reading the newspaper and watching television. 4. Eye medications will need to be administered for the rest of your life.

572. 4 Rationale: The administration of eyedrops is a critical component of the treatment plan for the client with glaucoma. 782The client needs to be instructed that medications will need to be taken for the rest of his or her life. Limiting fluids and reducing salt will not decrease intraocular pressure. Option 3 is not necessary.

573. The nurse is assigned to care for a client with a detached retina. Which finding should the nurse expect to be documented in the client's record? 1. Blurred vision 2. Pain in the effected eye 3. A yellow discoloration of the sclera 4. A sense of a curtain falling across the field of vision

573. 4 Rationale: A characteristic clinical manifestation of retinal detachment described by clients is the feeling that a shadow or curtain is falling across the field of vision. There is no pain associated with detachment of the retina. A retinal detachment is an ophthalmic emergency and even more so if visual acuity is still normal. Options 1 and 3 are not specifically associated with a detached retina.

574. The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? 1. Total loss of vision 2. A reddened conjunctiva 3. A sudden sharp pain in the eye 4. Complaints of a burst of black spots or floaters

574. 4 Rationale: Complaints of a sudden burst of black spots or floaters indicate that bleeding has occurred as a result of the detachment. Options 1, 2, and 3 are not specifically associated with bleeding as a result of detached retina.

575. A client arrives in the emergency department after an automobile crash. The client's forehead hit the steering wheel, and a hyphema has been diagnosed. Which position should the nurse prepare to position the client? 1. Flat on bed rest 2. On bed rest in a semi-Fowler's position 3. In lateral position on the unaffected side 4. In the lateral position on the affected side

575. 2 Rationale: A hyphema is the presence of blood in the anterior chamber. It is produced when a force is sufficient to break the integrity of the blood vessels in the eye. It can be caused by direct injury, such as a penetrating injury from a BB pellet, or indirectly, such as from striking the forehead on a steering wheel during an accident. The client is treated by bed rest in a semi-Fowler's position to assist gravity in keeping the hyphema away from the optical center of the cornea

576. A client sustains a contusion of the eyeball after a traumatic injury with a blunt object. The nurse should take which immediate action? 1. Notify the health care provider (HCP) 2. Apply ice to the affected eye 781 3. Irrigate the eye with cool water 4. Accompany the client to the emergency department

576. 2 Rationale: Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client should receive a thorough eye examination to rule out the presence of other eye injuries. Eye irrigation is not indicated in a contusion. Options 1 and 4 will delay immediate treatment. After the application of ice, the HCP would be notified.

577. A client sustains a chemical eye injury from a splash of battery acid. The nurse should prepare the client for which immediate measure? 1. Checking visual acuity 2. Covering the eye with a pressure patch 3. Swabbing the eye with antibiotic ointment 4. Irrigating the eye with sterile normal saline

577. 4 Rationale: Emergency care after a chemical burn to the eye includes irrigating the eye immediately with sterile normal saline or ocular irrigating solution. The irrigation should be maintained for at least 10 minutes. After this emergency treatment, visual acuity is assessed. Options 2 and 3 are not immediate measures.

578. The nurse is caring for a client after enucleation and notes the presence of bright red drainage on the dressing. The nurse should take which appropriate action? 1. Document the finding 2. Continue to monitor vital signs 3. Report the finding to the registered nurse (RN) 4. Mark the drainage on the dressing and monitors for any increase in bleeding

578. 3 Rationale: If the nurse notes the presence of bright red drainage on the dressing, it must be reported to the registered nurse 783because this can indicate hemorrhage. Options 1, 2, and 4 will delay necessary treatment.

579. The nurse is preparing to administer eardrops to an adult client. The nurse administers the eardrops by which technique? 1. Pulling the pinna up and back 2. Pulling the earlobe down and back 3. Tilting the client's head forward and down 4. Instructing the client to stand and lean to one side

579. 1 Rationale: The nurse tilts the client's head slightly away and pulls the pinna up and back. Asking the client to stand and lean to one side is inappropriate and unsafe.

580. The nurse is caring for a client who is hearing-impaired and should take which approach to facilitate communication? 1. Speak loudly 2. Speak frequently 3. Speak in a normal tone 4. Speak directly into the impaired ear

580. 3 Rationale: It is important to speak in a normal tone to the client with impaired hearing and avoid shouting. The nurse should talk directly to the client while facing the client and should speak clearly. If the client does not seem to understand what is said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but it is important to avoid talking directly into the impaired ear.

581. A client arrives at the emergency department with a foreign body in the left ear that has been determined to be an insect. Which initial intervention should the nurse anticipate to be prescribed? 1. Irrigation of the ear 2. Instillation of antibiotic eardrops 3. Instillation of corticosteroid ointment 4. Instillation of mineral oil or diluted alcohol

581. 4 Rationale: Insects are killed before removal unless they can be coaxed out by a flashlight or a humming noise. Mineral oil or diluted alcohol is instilled into the ear to suffocate the insect, which is then removed by using ear forceps. When the foreign object is vegetable matter, irrigation is not used because this material expands with hydration and the impaction becomes worse. Options 1, 2, and 3 may be prescribed after the initial treatment if necessary and if inflammation or infection is a concern.

582. The nurse notes that the health care provider has documented a diagnosis of presbycusis on the client's chart. The nurse understands that this condition is accurately described as which? 1. Tinnitus that occurs with aging 2. Nystagmus that occurs with aging 3. A conductive hearing loss that occurs with aging 4. A sensorineural hearing loss that occurs with aging

582. 4 Rationale: Presbycusis is a type of hearing loss that occurs with aging. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. Options 1, 2, and 3 are not accurate descriptions.

583. A client with Ménière's disease is experiencing severe vertigo. The nurse reinforces instructions to the client to do which to assist in controlling the vertigo? 1. Increase sodium in the diet. 2. Lie still and watch television. 3. Avoid sudden head movements. 4. Increase fluid intake to 3000 mL/day.

583. 3 Rationale: The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Watching television can increase the vertigo.

584. The nurse is assigned to care for a client hospitalized with Ménière's disease. The nurse expects that which would most likely be prescribed for the client? 1. Low-fat diet 2. Low-sodium diet 3. Low-cholesterol diet 4. Low-carbohydrate diet

584. 2 Rationale: Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed. Options 1, 3, and 4 are not specific dietary prescriptions for this condition.

585. A client is diagnosed with glaucoma. Which data gathered by the nurse indicate a risk factor associated with glaucoma? 1. Cardiovascular disease 2. A history of migraine headaches 3. Frequent urinary tract infections 4. Frequent upper respiratory infections

585. 1 Rationale: Hypertension, cardiovascular disease, diabetes mellitus, and obesity are associated with the development of glaucoma. Smoking, ingestion of caffeine or large amounts of alcohol, illicit drugs, corticosteroids, altered hormone levels, posture, and eye movements may cause varying transient increases in intraocular pressure.

586. Betaxolol hydrochloride (Betoptic) eyedrops have been prescribed for the client with glaucoma. Which nursing action is most appropriate related to monitoring for the side/adverse effects of this medication? 1. Monitoring temperature 2. Monitoring blood pressure 3. Checking peripheral pulses 4. Checking the blood glucose level

586. 2 Rationale: Hypotension, dizziness, nausea, diaphoresis, headache, fatigue, constipation, and diarrhea are systemic effects of the medication. Nursing interventions include monitoring the blood pressure for hypotension and assessing the pulse for strength, weakness, irregular rate, and bradycardia. Options 1, 3, and 4 are not specifically associated with this medication.

587. The nurse assists to prepare the client for ear irrigation as prescribed by the health care provider. Which action should the nurse plan to take? 1. Warm the irrigating solution to 98°F. 2. Position the client with the affected side up after the irrigation. 3. Direct a slow, steady stream of irrigation solution toward the eardrum. 4. Assist the client to turn his or her head so that the ear to be irrigated is facing upward.

587. 1 Rationale: Irrigation solutions that are not close to the client's body temperature can be uncomfortable and may cause injury, nausea, and vertigo. The client is positioned so that the ear to be irrigated is facing downward, because this allows gravity to assist in the removal of the ear wax and solution. After the irrigation, the client is to lie on the affected side to finish draining the irrigating solution. A slow, steady stream of solution should be directed toward the upper wall of the ear canal and not toward the eardrum. Too much force could cause the tympanic membrane to rupture.

588. In preparation for cataract surgery, the nurse is to administer cyclopentolate (Cyclogyl) eyedrops. The nurse administers the eyedrops knowing that the purpose of this medication is which? 1. Produce miosis of the operative eye 2. Dilate the pupil of the operative eye 3. Provide lubrication to the operative eye 4. Constrict the pupil of the operative eye

588. 2 Rationale: Cyclopentolate is a rapidly acting mydriatic and cycloplegic medication. Cyclopentolate is effective in 25 to 75 minutes, and accommodation returns in 6 to 24 hours. Cyclopentolate is used for preoperative mydriasis.

589. The nurse is providing instructions to a client who will be self-administering eyedrops. To minimize the systemic effects that eyedrops can produce, the client is instructed to perform which? 1. Eat before instilling the drops. 2. Swallow several times after instilling the drops. 3. Blink vigorously to encourage tearing after instilling the drops. 793 4. Occlude the nasolacrimal duct with a finger over the inner canthus for 30 to 60 seconds after instilling the drops.

589. 4 Rationale: Applying pressure on the nasolacrimal duct prevents systemic absorption of the medication. Options 1, 2, and 3 will not prevent systemic absorption.

590. The client is receiving an eyedrop and an eye ointment to the right eye. Which action should the nurse take? 1. Administer the eyedrop first, followed by the eye ointment. 2. Administer the eye ointment first, followed by the eyedrop. 3. Administer the eyedrop, wait 10 minutes, and administer the eye ointment. 4. Administer the eye ointment, wait 10 minutes, and administer the eyedrop.

590. 1 Rationale: When an eyedrop and an eye ointment is scheduled to be administered at the same time, the eyedrop is administered first. Options 2, 3, and 4 are incorrect.

591. The nurse is caring for a client with glaucoma. Which medication prescribed for the client should the nurse question? 1. Betaxolol (Betoptic) 2. Pilocarpine (Ocusert Pilo-20) 3. Atropine sulfate (Isopto Atropine) 4. Pilocarpine hydrochloride (Isopto Carpine)

591. 3 Rationale: Options 1, 2, and 4 are miotic agents used to treat glaucoma. Option 3 is a mydriatic and cycloplegic medication, and its use is contraindicated in clients with glaucoma. Mydriatic medications dilate the pupil and can cause an increase in intraocular pressure in the eye.

592. The nurse is preparing to administer eyedrops. Which interventions should the nurse take to administer the drops? Select all that apply. 1. Wash hands. 2. Put on gloves. 3. Place the drop in the conjunctival sac. 4. Pull the lower lid down against the cheekbone. 5. Instruct the client to squeeze the eyes shut after instilling the eyedrop. 6. Instruct the client to tilt the head forward, open the eyes, and look down.

592. 1, 2, 3, 4 Rationale: To administer eye medications, the nurse would wash hands and put on gloves. The client is instructed to tilt the head backward, open the eyes, and look up. The nurse pulls the lower lid down against the cheekbone and holds the bottle like a pencil, with the tip downward.

593. A client was just admitted to the hospital to rule out a gastrointestinal (GI) bleed. The client has brought several bottles of medications prescribed by different specialists. During the admission assessment, the client states, "Lately, I have been hearing some roaring sounds in my ears, especially when I am alone." Which medication should the nurse determine to be the cause of the client's complaint? 1. Doxycycline (Vibramycin) 2. Acetylsalicylic acid (aspirin) 3. Atropine sulfate (Isopto Atropine) 4. Diltiazem hydrochloride (Cardizem)

593. 2 Rationale: Aspirin is contraindicated for gastrointestinal bleed and is potentially ototoxic. The client should be advised to notify the prescribing health care provider so the medication can be discontinued and/or a substitute that is less toxic to the ear can be taken instead. Options 1, 3, and 4 do not have side effects that are potentially associated with hearing difficulties.

594. Pilocarpine hydrochloride (Isopto Carpine) is prescribed for the client with glaucoma. Which medication should the nurse plan to have available in the event of systemic toxicity? 1. Atropine sulfate 2. Timolol maleate (Timoptic) 3. Metipranolol (OptiPranolol) 4. Carteolol hydrochloride (Ocupress)

594. 1 Rationale: Systemic absorption of pilocarpine hydrochloride can produce toxicity and includes manifestations of vertigo, bradycardia, tremors, hypotension, and seizures. Atropine sulfate must be available in the event of systemic toxicity. Pindolol, timolol maleate, and carteolol hydrochloride are β-blockers.

595. A miotic medication has been prescribed for the client with glaucoma. The client asks the nurse about the purpose of the medication. The nurse should tell the client which? 1. "The medication will help dilate the eye to prevent an increase in eye pressure." 2. "The medication will relax the muscles of the eyes and prevent blurred vision." 3. "The medication causes the pupil to constrict and will lower the pressure in the eye." 4. "The medication will help block the responses that are sent to the muscles in the eye."

595. 3 Rationale: Miotics cause pupillary constriction and are used to treat glaucoma. They lower the intraocular pressure, thereby increasing blood flow to the retina and decreasing retinal damage and loss of vision. Miotics cause a contraction of the ciliary muscle and a widening of the trabecular meshwork. Options 1, 2, and 4 are incorrect.

597. The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care? 1. "I should drink extra fluids for the remainder of the day." 2. "I should not take any medication for at least 4 hours." 3. "I should eat lightly for the remainder of the day." 4. "I should rest quietly for the remainder of the day."

597. 1 Rationale: After CT scanning, the client may resume all usual activities. The client should be encouraged to take in extra fluids to replace those lost with diuresis from the contrast dye. Options 2, 3, and 4 are unnecessary. Test-Taking Strategy: Eliminate options 3 and 4 because they are comparable or alike. Next, focus the subject, that a contrast medium was given. This will direct you to the correct option. Review: computed tomography scan.

598. The nurse is caring for a client with increased intracranial pressure (ICP). Which change in vital signs would occur if ICP is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing BP 2. Decreasing temperature, decreasing pulse, increasing respirations, decreasing BP 3. Decreasing temperature, increasing pulse, decreasing respirations, increasing BP 4. Increasing temperature, decreasing pulse, decreasing respirations, increasing BP

598. 4 Rationale: A change in vital signs may be a late sign of increased ICP. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities may also arise.823 Test-Taking Strategy: Think about the pathophysiology of increased ICP. If you remember that blood pressure rises, you are able to eliminate options 1 and 2 as comparable or alike. To select from the remaining options, remember that the temperature rises. Review: increased ICP.

599. The nurse observes the unlicensed assistive personnel (UAP) positioning the client with increased intracranial pressure (ICP). Which position would require intervention by the nurse? 1. Head midline 2. Head turned to the side 3. Neck in neutral position 4. Head of bed elevated 30 to 45 degrees

599. 2 Rationale: The head of the client with increased ICP should be positioned so that the head is in a neutral, midline position. The nurse should avoid flexing or extending the neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees. Use of proper positions promotes venous drainage from the cranium to keep ICP down.

600. The client recovering from a head injury is arousable and participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure (ICP) if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

600. 4 Rationale: Activities that increase intrathoracic and intraabdominal pressures cause indirect elevation of the ICP. Some of these activities include isometric exercises, Valsalva maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising.

601. The client has clear fluid leaking from the nose after a basilar skull fracture. The nurse determines that this is cerebrospinal fluid (CSF) if the fluid meets which criteria? 1. Is grossly bloody in appearance and has a pH of 6 2. Clumps together on the dressing and has a pH of 7 3. Is clear in appearance and tests negative for glucose 4. Separates into concentric rings and tests positive for glucose

601. 4 Rationale: Leakage of CSF from the ears or nose may accompany basilar skull fracture. It can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, which is known as the halo sign. It also tests positive for glucose. Options 1, 2, and 3 are not characteristics of CSF.

602. The client is admitted to the hospital for observation with a probable minor head injury after an automobile crash. The nurse expects the cervical collar will remain in place until which time? 1. The client is taken for spinal x-rays 2. The family comes to visit after surgery 3. The nurse needs to provide physical care 4. The health care provider reviews the x-ray results

602. 4 Rationale: There is a significant association between cervical spine injury and head injury. For this reason, the nurse leaves any form of spinal immobilization in place until lateral cervical spine x-rays rule out fracture or other damage and the results have been reviewed by the health care provider.

603. The client was seen and treated in the emergency department (ED) for a concussion. Before discharge, the nurse explains the signs/symptoms of a worsening condition. The nurse determines that the family needs further teaching if they state they will return to the ED if the client experiences which sign/symptom? 1. Vomiting 2. Minor headache 3. Difficulty speaking 4. Difficulty awakening

603. 2 Rationale: A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the health care provider or return the client to the emergency department if certain signs and symptoms are noted. These include confusion, difficulty awakening or speaking, one-sided weakness, vomiting, or severe headache. Minor headache is expected.

604. The nurse is caring for a client who has undergone craniotomy with a supratentorial incision. The nurse should plan to place the client in which position postoperatively? 1. Head of bed flat, head and neck midline 2. Head of bed flat, head turned to the nonoperative side 822 3. Head of bed elevated 30 to 45 degrees, head and neck midline 4. Head of bed elevated 30 to 45 degrees, head turned to the operative side

604. 3 Rationale: Following supratentorial surgery, the head of the bed is kept at a 30- to 45-degree angle. The head and neck should not be angled either anteriorly or laterally, but rather should be kept in a neutral (midline) position. This will promote venous return through the jugular veins, which will help prevent a rise in intracranial pressure.

605. The client with a cervical spine injury has Crutchfield tongs applied in the emergency department. The nurse should perform which essential action when caring for this client? 1. Providing a standard bed frame 2. Removing the weights to reposition the client 3. Removing the weights if the client is uncomfortable 4. Comparing the amount of prescribed weights with the amount in use

605. 4 Rationale: Crutchfield tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. The nurse ensures that weights hang freely and that the amount of weight matches the current prescription. The client with Crutchfield tongs is placed on a Stryker frame or Roto-Rest bed. The nurse does not remove the weights to administer care or change the level of tension or traction based on client comfort level.

606. The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? 1. "I will use a straw for drinking." 2. "I will drive only during the daytime." 3. "I will use caution because the device alters balance." 4. "I will wash the skin daily under the lamb's-wool liner of the vest."

606. 2 Rationale: The client should not drive because the device impairs the range of vision. The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest or the device to protect the skin from ulceration and should use powder or lotions sparingly or not at all. The wool liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed.

607. The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted? 1. Sudden tachycardia 2. Pallor of the face and neck 3. Severe, throbbing headache 4. Severe and sudden hypotension

607. 3 Rationale: The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

608. The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action? 1. Strictly adhering to a bowel retraining program 2. Keeping the linen wrinkle-free under the client 3. Avoiding unnecessary pressure on the lower limbs 4. Limiting bladder catheterization to once every 12 hours

608. 4 Rationale: The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in the tubing. It is not appropriate to catheterize the client every 12 hours. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

609. The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action should the nurse take? 1. Raise the head of the bed and remove the noxious stimulus 2. Lower the head of the bed and remove the noxious stimulus 3. Lower the head of the bed and administer an antihypertensive agent 4. Remove the noxious stimulus and administer an antihypertensive agent

609. 1 Rationale: Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. Client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

610. The client is having a lumbar puncture (LP) performed. The nurse should place the client in which position for the procedure? 1. Supine, in semi-Fowler's 2. Prone, in slight Trendelenburg's 3. Prone, with a pillow under the abdomen 4. Side-lying, with legs pulled up and chin to the chest

610. 4 Rationale: The client undergoing a lumbar puncture (LP) is positioned lying on the side, with the knees bent, drawn up to the abdomen, and the chin tucked into the chest. This position helps to open the spaces between the vertebrae.

611. The client with myasthenia gravis is suspected of having cholinergic crisis. Which sign/symptom indicates this crisis is taking place? 1. Ataxia 2. Mouth sores 3. Hypothermia 4. Hypertension

611. 4 Rationale: Cholinergic crisis occurs as a result of an overdose of medication. Indications of cholinergic crisis include gastrointestinal disturbances, nausea, vomiting, diarrhea, abdominal cramps, increased salivation and tearing, miosis, hypertension, sweating, and increased bronchial secretions.

612. The client is receiving meperidine hydrochloride (Demerol) for pain. Which are side/adverse effects of this medication? Select all that apply. 1. Diarrhea 2. Tremors 3. Drowsiness 4. Hypotension 5. Urinary frequency 6. Increased respiratory rate

612. 2, 3, 4 Rationale: Meperidine hydrochloride is an opioid analgesic. Side/adverse effects include respiratory depression, drowsiness, hypotension, constipation, urinary retention, nausea, vomiting, and tremors.

613. The client with myasthenia gravis becomes increasingly weak. The health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or increasing severity of the disease (myasthenic crisis). An injection of edrophonium (Enlon) is administered. Which indicates that the client is in cholinergic crisis? 1. No change in the condition 2. Complaints of muscle spasms 3. An improvement of the weakness 4. A temporary worsening of the condition

613. 4 Rationale: An edrophonium (Enlon) injection makes the client in cholinergic crisis temporarily worse. This is known as a negative test. An improvement of weakness would occur if the client were experiencing myasthenia gravis. Options 1 and 2 would not occur in either crisis.

614. Carbidopa-levodopa (Sinemet) is prescribed for a client with Parkinson's disease, and the nurse monitors the client for adverse effects of the medication. Which sign/symptom indicates the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

614. 4 Rationale: Dyskinesia and impaired voluntary movement may occur with high levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia (the temporary muscle weakness that lasts 1 minute to 1 hour, also known as the "on-off phenomenon") are frequent side effects of the medication.

615. Phenytoin (Dilantin), 100 mg orally three times daily, has been prescribed for a client for seizure control. The nurse reinforces instructions regarding the medication to the client. Which statement by the client indicates an understanding of the instructions? 1. "I will use a soft toothbrush to brush my teeth." 2. "It's all right to break the capsules to make it easier for me to swallow them." 3. "If I forget to take my medication, I can wait until the next dose and eliminate that dose." 4. "If my throat becomes sore, it's a normal effect of the medication and it's nothing to be concerned about." 836

615. 1 Rationale: Phenytoin (Dilantin) is an anticonvulsant. Gingival hyperplasia, bleeding, swelling, and tenderness of the gums can occur with the use of this medication. The client needs to be taught good oral hygiene, gum massage, and the need for regular dentist visits. The client should not skip medication doses because this could precipitate a seizure. Capsules should not be chewed or broken, and they must be swallowed. The client needs to be instructed to report a sore throat, fever, glandular swelling, or any skin reaction because this indicates hematological toxicity.

616. The client is taking phenytoin (Dilantin) for seizure control, and a blood sample for a serum drug level is drawn. Which laboratory finding indicates a therapeutic serum drug result? 1. 5 mcg/mL 2. 15 mcg/mL 3. 25 mcg/mL 4. 30 mcg/mL

616. 2 Rationale: The therapeutic serum drug level range for phenytoin (Dilantin) is 10 to 20 mcg/mL. Therefore, options 1, 3, and 4 are incorrect. Test-Taking Strategy: Knowledge regarding the subject, the therapeutic serum range of phenytoin, is required to answer the question. A helpful hint may be to remember that the theophylline therapeutic range and the acetaminophen (Tylenol) therapeutic range are the same as the phenytoin (Dilantin) therapeutic range. Remembering this may assist you when answering questions related to any of these three medications. Review: therapeutic phenytoin level.

617. Ibuprofen (Advil) is prescribed for a client. Which instruction should the nurse give the client about taking this medication? 1. Take with 8 oz of milk. 2. Take in the morning after arising. 3. Take 60 minutes before breakfast. 4. Take at bedtime on an empty stomach.

617. 1 Rationale: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID). NSAIDs should be given with milk or food to prevent gastrointestinal irritation. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Note that options 2, 3, and 4 are comparable or alike. Each of these options indicates administering the medication without food. Remember, NSAIDs can cause gastric irritation. Review: nonsteroidal anti-inflammatory medications.

618. The nurse is caring for a client who is taking phenytoin (Dilantin) for control of seizures. During data collection, the nurse notes that the client is taking birth control pills. Which information should the nurse provide to the client? 1. Pregnancy should be avoided while taking phenytoin (Dilantin). 2. The client may stop taking the phenytoin (Dilantin) if it is causing severe gastrointestinal effects. 3. The potential for decreased effectiveness of the birth control pills exists while taking phenytoin (Dilantin). 4. The increased risk of thrombophlebitis exists while taking phenytoin (Dilantin) and birth control pills together.

618. 3 Rationale: Phenytoin (Dilantin) enhances the rate of estrogen metabolism, which can decrease the effectiveness of some birth control pills. Options 1, 2, are 4 are not accurate. Test-Taking Strategy: Recall knowledge of the subject, medication interactions between phenytoin and birth control pills. Option 4 is not an appropriate statement because it would cause anxiety in the client. A client should not be instructed to stop anticonvulsant medication. Pregnancy does not need to be "avoided." Review: phenytoin (Dilantin).

619. The client with trigeminal neuralgia is being treated with carbamazepine (Tegretol). Which laboratory result indicates that the client is experiencing an adverse effect of the medication? 1. Sodium level, 140 mEq/L 2. Uric acid level, 5.0 mg/dL 3. White blood cell count, 3000 cells/mm3 4. Blood urea nitrogen (BUN) level, 15 mg/dL

619. 3 Rationale: Adverse effects of carbamazepine (Tegretol) appear as blood dyscrasias, including aplastic anemia, agranulocytosis, thrombocytopenia, leukopenia, cardiovascular disturbances, thrombophlebitis, dysrhythmias, and dermatological effects. Options 1, 2, and 4 identify normal laboratory values.

620. The client with myasthenia gravis is receiving pyridostigmine (Mestinon). The nurse monitors for signs and symptoms of cholinergic crisis caused by overdose of the medication. The nurse checks the medication supply to ensure that which medication is available for administration if a cholinergic crisis occurs? 1. Vitamin K 2. Acetylcysteine 3. Atropine sulfate 4. Protamine sulfate

620. 3 Rationale: The antidote for cholinergic crisis is atropine sulfate. Acetylcysteine is the antidote for acetaminophen (Tylenol). Vitamin K is the antidote for warfarin (Coumadin) and protamine sulfate is the antidote for heparin. Test-Taking Strategy: Knowledge regarding the subject, antidotes for various medications, is needed to answer this question. Remember that atropine sulfate is the antidote for cholinergic crisis. Review: antidote for pyridostigmine (Mestinon).