COMPLEX EXAM 3

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

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

The nurse is instructing a client with Parkinson's disease about preventing falls. Which client statement reflects a need for further teaching? 1. "I can sit down to put on my pants and shoes." 2. "I try to exercise every day and rest when I'm tired." 3. "My son removed all loose rugs from my bedroom." 4. "I don't need to use my walker to get to the bathroom."

"I don't need to use my walker to get to the bathroom." Rationale: The client with Parkinson's disease should be instructed regarding safety measures in the home. The client should use her or his walker as support to get to the bathroom because of bradykinesia. The client should sit down to put on pants and shoes to prevent falling. The client should exercise every day in the morning when energy levels are highest. The client should have all loose rugs in the home removed to prevent falling.

The nurse has completed teaching for a client newly diagnosed with Parkinson's disease. What statement indicates teaching has been effective? A) "I have an increased level of glutamate" B) "I have a decreased level of acetylcholine" C) "I have a decreased level of dopamine" D) "I have an increased level of serotonin"

"I have a decreased level of dopamine"

The nurse provides home care instructions to a client with systemic lupus erythematosus and tells the client about methods to manage fatigue. Which statement by the client indicates a need for further instruction? 1. "I should take hot baths because they are relaxing." 2. "I should sit whenever possible to conserve my energy." 3. "I should avoid long periods of rest because it causes joint stiffness." 4. "I should do some exercises, such as walking, when I am not fatigued."

"I should take hot baths because they are relaxing." Rationale: To help reduce fatigue in the client with systemic lupus erythematosus, the nurse should instruct the client to sit whenever possible, avoid hot baths (because they exacerbate fatigue), schedule moderate low-impact exercises when not fatigued, and maintain a balanced diet. The client is instructed to avoid long periods of rest because it promotes joint stiffness.

Family members of a patient who has a traumatic brain injury ask the nurse about the purpose of the ventriculostomy system being used for intracranial pressure monitoring. Which response by the nurse is best for this situation? A."This type of monitoring system is complex, and it is managed by skilled staff." B."The monitoring system helps show whether blood flow to the brain is adequate." C."The ventriculostomy monitoring system helps check for changes in cerebral perfusion pressure." D."This monitoring system has many benefits, including the ability to drain cerebrospinal fluid."

"The monitoring system helps show whether blood flow to the brain is adequate." Short, simple, and accurate explanations should be given initially to patients and family members. Explaining that the system is complex, and it is managed by skilled staff or that it has multiple benefits does not address the family question about purpose for this patient. Terminology such as ventriculostomy and cerebral perfusion pressure is too complex for the initial explanation and may increase family members' anxiety.

A 38-year-old woman has newly diagnosed multiple sclerosis (MS) and asks the nurse what is going to happen to her. What is the best response by the nurse? a. "You will have either periods of attacks and remissions or progression of nerve damage over time." b. "You need to plan for a continuous loss of movement, sensory functions, and mental capabilities." c. "You will most likely have a steady course of chronic progressive nerve damage that will change your personality." d. "It is common for people with MS to have an acute attack of weakness and then not to have any other symptoms for years."

"You will have either periods of attacks and remissions or progression of nerve damage over time." Most patients with multiple sclerosis (MS) have remissions and exacerbations of neurologic dysfunction or a relapsing-remitting initial course followed by progression with or without occasional relapses, minor remissions, and plateaus that progressively cause loss of motor, sensory, and cerebellar functions.

ERCP, patient understanding🡪

"look at" my gallbladder and bile duct. Key word is "look at"

The nurse is caring for a client with continuous intracranial pressure. The BP is 102/51 and the ICP is 20. After calculating the clients cerebral perfusion pressure (CPP), the nurses first action should be: a. Continue to monitor the client b. Place the head of bed is less than 30 degrees c. administer antihypertension medication as ordered d. inform the hcp

(102+(2*51)/3 = 68 -20 = 48 LOW d. inform the hcp

C5 injury🡪

......phrenic nerve (key word)

After the emergency department nurse has received a status report on the following patients with head injuries, which patient should the nurse assess first? A.A 20-yr-old patient whose cranial x-ray shows a linear skull fracture B.A 30-yr-old patient who lost consciousness for 10 seconds after a fall C.A 40-yr-old patient who has an initial Glasgow Coma Scale score of 13 D.A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light

A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased intracranial pressure. The other patients are not at immediate risk for complications such as herniation.

The nurse is assessing a group of clients. Which client is at highest risk for developing GBS?

A client has some type of PNEUMONIA infection (CANT READ IT)

A client with myasthenia gravis has become increasingly weaker. The primary health care provider prepares to identify whether the client is reacting to an overdose of the medication (cholinergic crisis) or an increasing severity of the disease (myasthenic crisis). An injection of edrophonium is administered. Which finding would indicate 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

A temporary worsening of the condition Rationale: An edrophonium injection makes the client in cholinergic crisis temporarily worse. An improvement in the weakness indicates myasthenia crisis. Muscle spasms are not associated with this test.

A client admitted for new onset seizure disorder. What statement indicates client teaching has been effective? A) "Ativan is used to stop a seizure" B) "Ativan is used to control my seizures" C) "I should take Ativan every morning to prevent seizures" D) "I should avoid using Ativan completely"

A) "Ativan is used to stop a seizure"

The nurse completed teaching for a client newly diagnosed with multiple sclerosis. What statement by the family indicates need for additional teaching? A) "I should expect her to have short term memory loss early on" B) "She could fall because she may lose her balance and coordination" C) "Eventually, she may not be able to drive because of vision problems" D) "She ma have difficulty eating, chewing, and swallowing"

A) "I should expect her to have short term memory loss early on"

The nurse has completed teaching a client recovering from hepatitis B. What statement indicates more teaching is required? A) "When the jaundice is gone, I have recovered from my illness and the infection is cured." B) "Until my tests for the virus is negative, I should use a condom for sexual intercourse" C) "My family members should be tested for hepatitis B" D) "I should not drink alcohol for at least the next year"

A) "When the jaundice is gone, I have recovered from my illness and the infection is cured."

A client is admitted with a traumatic brain injury. What assessment findings would indicate the need for immediate action? A) A Glasgow Coma Scale (GSC) of 6 B) A blood sugar level of 300 C) A temperature of 97.0 F D) A complaint of nausea

A) A Glasgow Coma Scale (GSC) of 6

The nurse is caring for a client experiencing status epilepticus. Which of the following is most accurate about treatment of this condition? A) Administer lorazepam (Ativan) IVP to stop seizure B) Conscious sedation is an option to stop seizure activity C) Administer a loading dose of phenytoin to stop the seizure D) Administer 10 mg of Phenobarbital IVP over 5 minutes

A) Administer lorazepam (Ativan) IVP to stop seizure

While assessing a client with cirrhosis, what findings best indicate the development of portal hypertension? SATA A) Ascites B) Hemorrhoids C) Muscle waiting D) Splenomegaly E) Headache

A) Ascites B) Hemorrhoids D) Splenomegaly

The nurse is planning to teach a client diagnosed with hepatitis A. What nursing interventions should the nurses include in the teaching plan? A) Encourage multiple small meals daily B) Provide relief from nausea and vomiting C) Implement an exercise program D) Administer pain medication E) Plan frequent rest periods

A) Encourage multiple small meals daily B) Provide relief from nausea and vomiting E) Plan frequent rest periods

The nurse is planning discharge teaching for the family of a client with advanced Parkinson's disease. What is the essential to include in the teaching plan? Select all that apply A) Ensure the client remains on bedrest for the majority of the day B) Teach the family about signs of caregiver fatigue C) Ensure all area rugs are removed from the house D) Ensure handrails and ramps are installed into the house E) Teach the family about exacerbation and remission episodes

A) Ensure the client remains on bedrest for the majority of the day C) Ensure all area rugs are removed from the house D) Ensure handrails and ramps are installed into the house E) Teach the family about exacerbation and remission episodes

The nurse is caring for a client with acute cholecystitis. When assessing the client, what signs and symptoms does the nurse expect? A) Epigastric pain and negative Murphy's sign B) Nausea and right lower quadrant tenderness C) Abdominal pain and headache D) Fever and Tachycardia

A) Epigastric pain and negative Murphy's sign

The nurse is teaching a client about signs and symptoms of cholinergic crisis. What will be included in the teaching plan? Select all that apply A) Frequent urination B) Double vision C) Dry mouth D) Diarrhea E) Increased perspiration

A) Frequent urination D) Diarrhea E) Increased perspiration

A nurse is caring for a client with an acute subdural hematoma. What prescription/order by the health care provider would the nurse question? A) Give aspirin by mouth daily B) Monitor for otorrhea C) Monitor for rhinorrhea D) Keep the head of bed elevated

A) Give aspirin by mouth daily

The nurse has received the laboratory results below on a client reporting nausea and vomiting. What health care provider prescription/order will the nurse implement first? WBC 28,000 U/L Amylase 480 U/L Lipase 425 U/L Calcium 6 mg/dL A) Lactated Ringers 1 liter over 30 minutes B) Toradol 30 mg IVP C) Abdominal X-Ray D) Ciprofloxacin 400 mg IV

A) Lactated Ringers 1 liter over 30 minutes

The nurse caring for client with intracranial pressure (ICP) monitoring notes the ICP is 24 mm/Hg. What is the priority action? A) Maintain midline positioning of the head B) Ask the client to cough and deep breath C) Inform the healthcare provider D) Place the head of the bed at 40-45 degrees

A) Maintain midline positioning of the head

The nurse is preparing to administer prescribed lactulose. What is the priority complication to monitor for when caring for the client receiving this medication? A) Potential for fails B) Potential for asterixis C) Potential for poor nutrient absorption D) Potential for diarrhea

A) Potential for fails

The nurse is caring for a client with an intracranial pressure (ICP) of 24 mmHg and a blood pressure 92/62 mmHg. Based on the client's cerebral perfusion pressure (CCP), what intervention is most appropriate? A) Raising the head of bed B) Keep head of bed the same C) Call the rapid response team D) Lowering the head of bed

A) Raising the head of bed

The nurse is preparing discharge teaching for a client with a C8 spinal cord injury. What is the most appropriate to include in the teaching plan? A) Teach the family to assist the client to be independent when possible B) Teach the client the inability to do any ADLs is expected C) Teach the family members to perform ADLs as much as possible D) Teach the client the importance of allowing dependence in daily activities

A) Teach the family to assist the client to be independent when possible

After receiving shift report, which client should the nurse assess first? A) The client with an L-2 spinal cord injury who is complaining of a sudden headache and visual disturbances B) The client with C-6 spinal cord injury who is complaining of occasional dyspnea and has a respiratory rate of 12 breaths per minute C) The client with a C-4 spinal cord injury who is on a ventilator and has a pulse oximeter reading of 98% D) The client with an L-4 spinal cord injury who is frightened and anxious about being transferred to the rehabilitation unit

A) The client with an L-2 spinal cord injury who is complaining of a sudden headache and visual disturbances

The nurse is preparing to discharge a first-time seizure client. What information would indicate the need for additional teaching? A. "I should not drive without another adult in the front seat to take over should a seizure occur." B. "I should engage in outside activity such as support groups at the local Epilepsy Foundation." C. "I should report issues relating to job discrimination to the U.S. Equal Employment Opportunity Commission (EEOC)." D. "I should utilize state agencies specializing in vocational rehabilitation services to aid in finding work"

A. "I should not drive without another adult in the front seat to take over should a seizure occur."

The nurse is teaching a client newly diagnosed with seizures about phenytoin. What statements indicate the teaching has been effective? Select all that apply. A. "I will take my medications as directed by my prescriber." B. "I may need to get my blood tested to evaluate medication levels." C. "I will need to maintain a written record of any side effects I think I have." D. "I will need to have my urine checked to evaluate for drug excretion levels." E. "I will not take my medications if I am feeling nauseated."

A. "I will take my medications as directed by my prescriber." B. "I may need to get my blood tested to evaluate medication levels." C. "I will need to maintain a written record of any side effects I think I have."

The nurse has completed teaching for a client newly diagnosed with Parkinson's disease. What statement, by the client, indicates for further discussion? A. "My gait is impaired because I have too much dopamine in my brain." B. "My gait is impaired because I have too much acetylcholine in my brain." C. "My gait is impaired because I have too little dopamine in my brain." D. "My gait is impaired because l have too much y-aminobutyric acid (GABA) action in my brain"

A. "My gait is impaired because I have too much dopamine in my brain."

A client with myasthenia gravis presents to the emergency department with excessive salivation, muscle fasciculations, and constricted pupils. What drug should the nurse anticipate administering for emergency treatment? A. Atropine sulfate B. Edrophonium C. Pyridostigmine D. Diphenhydramine

A. Atropine sulfate

The nurse is caring for a client with systemic lupus erythematosus. What assessment findings would the nurse expect for this client? A. Butterfly rash and alopecia B. Pain in multiple joints and Cullen's sign C. Trousseau's sign and hypertension D. Diaphoresis and fever

A. Butterfly rash and alopecia

A client with an elected intracranial (ICP) reading is prescribed Mannitol. What would best indicate the medication was effective? A. Clients Glasgow coma scale (GCS) score increased from 9 to 13 B. Clients systolic blood pressure increases for 110 to 130 mmHG C. Clients pupils increased in size form 3 mm to 6 mm D. Client reports decreased pain level from 8 out of 10 to 4 out of 10

A. Clients Glasgow coma scale (GCS) score increased from 9 to 13

The nurse is caring for a client with an intracranial pressure (ICP) of 24 mmHG and a blood pressure of 92/62 mmHg. Based on the client's cerebral perfusion pressure (CPP), what intervention are appropriate? Select all that apply. A. Cluster care to decrease stimulation of the client B. Ensure the client is maintaining neutral head alignment C. Lower the clients head of bed to 10 degrees D. Increase the client's head of the bed to 30 degrees E. Encourage the client to turn, cough, and deep breathe

A. Cluster care to decrease stimulation of the client B. Ensure the client is maintaining neutral head alignment D. Increase the client's head of the bed to 30 degrees

A client is admitted to the hospital with Multiple Sclerosis. Which of the following nursing interventions would be most appropriate to implement for early stage symptoms? A. Initiate safety precautions to prevent falls from visual deficits. B. Monitor intake and output to assess for urinary retention. C. Encourage vigorous exercise to prevent disease progression. D. Advise the client to take their steroids on an empty stomach.

A. Initiate safety precautions to prevent falls from visual deficits.

What is NOT a complication of cirrhosis? A. Jaundice B. Encephalopathy C. Portal Hypertension D. Gastric Varices

A. Jaundice Response In the setting of cirrhosis, jaundice, peripheral edema, and ascites develop gradually as the liver fails and becomes fibrotic. Major complications of cirrhosis are portal hypertension, esophageal and gastric varices, peripheral edema, abdominal ascites, hepatic encephalopathy.

The nurse is caring for a client with an intracranial pressure (ICP) monitor in place. What is most important to report to the HCP? A. Oral temp 100.9F B. Intracranial pressure (ICP) 16 mmHg C. Cerebral perfusion pressure (CPP) 85 mmHg D. Apical pulse 106 bpm

A. Oral temp 100.9F

A nurse is caring for a client with rapidly progressing Guillain-Barre' Syndrome. What are the nursing actions for this client? Select all that apply. A. Prepare for ICU admission and possible intubation. B. Expect recovery in 2-7 days. C. Explain to the family that recovery is rare. D. Prepare to administer immunoglobulin. E. Assess for ascending paralysis and loss of cranial nerves.

A. Prepare for ICU admission and possible intubation. D. Prepare to administer immunoglobulin. E. Assess for ascending paralysis and loss of cranial nerves.

The nurse is caring for a client who has developed a hepatitis B infection. When the client asks how they got the infection, what answers should the nurse give? Select all that apply. A. Sharing contaminated needles B. Sexual activity with an infected person C. Eating contaminated food D. Living in a homeless shelter E. Traveling to a foreign country

A. Sharing contaminated needles B. Sexual activity with an infected person

The nurse is caring for a client with systemic lupus erythematosus. What lab findings would indicate a complication? A. protein in the urine B. elevate b-type natriuretic peptide (BNP) C. elevated amylase D. decreased sodium

A. protein in the urine

Which collaborative and nursing actions should the nurse include in the plan of care for a patient who experienced a T2 spinal cord transection 24 hours ago? (Select all that apply.) A. Urinary catheter care B. Nasogastric (NG) tube feeding C. Continuous cardiac monitoring D. Administration of H2 receptor blockers E. Maintenance of a warm room temperature

A.Correct Urinary catheter care C.Correct Continuous cardiac monitoring D.Correct Administration of H2 receptor blockers E.Correct Maintenance of a warm room temperature The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers. Gastrointestinal motility is decreased initially, and NG suctioning is indicated.

A male patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). He is now reporting a headache. Which prescribed intervention should the nurse implement first? A. Administer IV 5% hypertonic saline. B. Draw blood for arterial blood gases (ABGs). C. Send patient for computed tomography (CT). D. Administer acetaminophen (Tylenol) 650 mg.

Administer IV 5% hypertonic saline. The patient's low sodium indicates that hyponatremia may be causing the cerebral edema. The nurse's first action should be to correct the low sodium level. Acetaminophen (Tylenol) will have minimal effect on the headache because it is caused by cerebral edema and increased intracranial pressure (ICP). Drawing ABGs and obtaining a CT scan may provide some useful information, but the low sodium level may lead to seizures unless it is addressed quickly.

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

Administer lorazepam (Ativan) 4 mg IV. To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Phenytoin will also be administered, but it is not rapidly acting. Patients who are experiencing tonic-clonic seizures are nonresponsive, although the nurse should assess LOC after the seizure.

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

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

Which action should the nurse recognize has the highest priority for a patient who was admitted 16 hours earlier with a C5 spinal cord injury? A. Cardiac monitoring for bradycardia B. Assessment of respiratory rate and effort C. Administration of low-molecular-weight heparin D. Application of pneumatic compression devices to legs

Assessment of respiratory rate and effort Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate for preventing deterioration or complications but are not as important as assessment of respiratory effort.

To prevent autonomic dysreflexia, which nursing action should the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level? A. Support selection of a high-protein diet. B. Discuss options for sexuality and fertility. C. Assist to plan a prescribed bowel program. D. Use quad coughing to strengthen cough efforts.

Assist to plan a prescribed bowel program. Fecal impaction is a common stimulus for autonomic hyperreflexia. Dietary protein, coughing, and discussing sexuality and fertility should be included in the plan of care but will not reduce the risk for autonomic hyperreflexia.

A client is admitted for new onset seizure disorder. What statement indicate client teaching has been effective?

Ativan is used to stop seizures.

MG ER

Atropine sulfate

The nurse has taught a client with systemic lupus erythematosus (SLE) how to avoid flare- up of systems. What statement best indicates teaching has been effective? A) "I will avoid stressful activities, people with infections, and over exposure to cold." B) "I will avoid people with infections, fatigue, and overexposure to sunlight." C) "I will avoid people with infections, exercise, and extreme temperatures." D) "I will avoid exposure to sunlight, fatigue, and physical activities."

B) "I will avoid people with infections, fatigue, and overexposure to sunlight."

The nurse is assessing a client with hepatic encephalopathy expects what finding? A) Severe dizziness when ambulating B) A tremor of the hand when the wrist is extended C) Ecchymotic area around the umbilicus D) Acute pain in joints of hands and feet

B) A tremor of the hand when the wrist is extended

The nurse is caring for a patient with cervical spinal cord injury. In order to properly stabilize the injured area, what will the nurse would include in the plan of care? A) Sit up in high foyers position B) Maintain head in a neutral position C) Maintain a supine position D) Remove the hard collar while in bed

B) Maintain head in a neutral position

While assessing a client, the nurse notices a yellow-blue discoloration around their peri-umbilical area. The nurse understands the sign is associated with what disorder? A) Cholecystitis B) Pancreatitis C) Hepatitis D) Cirrhosis

B) Pancreatitis

The nurse is caring for a client with massive hemorrhage from esophageal varices. In planning care for this client, what is the priority? A) Plan measures to prevent caloric deficit B) Plan measures to ensure the airway remains patent C) Plan measures to control hemorrhage D) Plan measures to relieve anxiety

B) Plan measures to ensure the airway remains patent

The nurse is planning discharge teaching for family of a client with advanced Parkinson's disease. What is essential to include in the teaching plan? Select all that apply. A) Ensure the client remains on bedrest for the majority of the day B) Teach the family about signs of caregiver fatigue C) Ensure all area rugs are removed from the house D) Ensure handrails and ramps are installed in the house E) Teach the family about exacerbation and remission episodes

B) Teach the family about signs of caregiver fatigue C) Ensure all area rugs are removed from the house D) Ensure handrails and ramps are installed in the house

After removing shift report, which client should the nurse should assess first? A) The client with an L-2 spinal cord injury who is complaining of a sudden headache and visual disturbances B) The client with a C-6 spinal cord injury who is complaining of occasional dyspnea and has a respiratory rate of 12 breaths per minute C) The client with a C-4 spinal cord injury who is on a ventilator and has a pulse oximeter reading of 90% D) The client with an L-4 spinal cord injury who is frightened and anxious about being transferred to the rehabilitation unit

B) The client with a C-6 spinal cord injury who is complaining of occasional dyspnea and has a respiratory rate of 12 breaths per minute

The nurse is caring for a client with Hepatitis. Along with a yellowish discoloration of the skin, what additional symptoms might the nurse expect? Select all apply A) pruritus B) dark urine C) neuropathy D) photosensitivity E) light or clay colored stools

B) dark urine E) light or clay colored stools

The nurse has taught a client with systemic lupus erythematosus how to avoid flare-ups. What statement best indicates teaching has been effective? A. "I will avoid stressful activities, people with infections, and over exposure to cold." B. "I will avoid people with infections, fatigue, and overexposure to sunlight." C. "I will avoid exposure to sunlight, fatigue, and physical activity." D. "I will avoid people with infections, exercise, and extreme temperatures.

B. "I will avoid people with infections, fatigue, and overexposure to sunlight."

The nurse educator is providing an in-service on pyridostigmine. What statement best indicates teaching has been effective? A. "The medication increases the amount of circulating dopamine" B. "The medication increases acetylcholine at the receptor sites" C. "The medication is prescribed to decrease muscle spasms" D. "The medication should only be taken at night with water"

B. "The medication increases acetylcholine at the receptor sites"

The nurse is assessing a group of clients. What client is at highest risk for developing Guillain-Barre syndrome? A. A client who had a urinary tract infection three months ago. B. A client taking antibiotics for a gastrointestinal infection. C. A client with systemic lupus erythematosus (SLE) who has a cough. D. A client who received vaccines six months ago.

B. A client taking antibiotics for a gastrointestinal infection.

The nurse is caring for a client in an outpatient setting. What information from the health history indicates the client could have contracted hepatitis C in the past? A. A transfusion of four units of packed red blood cells in 2000. B. A history of illicit IV drug use 30 years ago. C. Travel to a country with unreliable food and water safety 90 days ago. D. Current frequent use of high doses of acetaminophen for joint pain.

B. A history of illicit IV drug use 30 years ago.

During a hepatitis A outbreak, a community health nurse working in a tribal community, is educating residents about how to protect themselves. What is the best information to include to avoid immediate exposure? A. Avoid eating pork or pork containing products. B. Boil water before drinking or using for cooking. C. Plan to get vaccinated immediately. D. Avoid contact with anyone exposed to hepatitis.

B. Boil water before drinking or using for cooking.

The nurse is admitting a client with a T-1 spinal cord injury to the intensive care unit. What information should the nurse give to the client and family? A. Shoulders will be fully functional, but hand strength will be weak. B. Full function of the client's arms will be retained. C. Total loss of respiratory function may occur temporarily. D. Elevations in heart rate are common with this type of injury.

B. Full function of the client's arms will be retained.

The nurse is caring for a client with a neurogenic bladder after a spinal fracture. As part of bladder training, what instructions should the nurse give to the client? A. You should try to drink at least 4L of fluids per day. B. Start by catheterizing yourself every 4 hours. C. Bear down as you empty your bladder to encourage the flow of urine. D. Take your antibiotics to prevent a urinary tract infection twice daily.

B. Start by catheterizing yourself every 4 hours.

Basilar Skull Fracture

Battle sign, rhinorrhea, vertigo

The patient's SCI is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient? a. Indoor mobility in manual wheelchair b. Ambulate with crutches and leg braces c. Be independent in self-care and wheelchair use d. Completely independent ambulation with short leg braces and canes

Be independent in self-care and wheelchair use With the injury at T4, the highest-level realistic goal for this patient is to be independent in self- care and wheelchair use because arm function will not be affected. Indoor mobility in a manual wheelchair will be achievable, but it is not the highest-level goal. Ambulating with crutches and leg braces can be achieved only by patients with injuries in T6-12 area. Independent ambulation with short leg braces and canes could occur for a patient with an L3-4 injury. (See Table 60.2.)

The nurse is caring for a client who has multiple sclerosis (MS). The client reports diplopia and sensory changes. What statement by the nurse is appropriate? A) "Participate in a vigorous exercise program" B) "Wear an eye patch on the right eye at all times" C) "Include rest periods throughout the day" D) "Use hot and cold therapy when needed"

C) "Include rest periods throughout the day"

The nurse is assessing a client who reports right upper quadrant pain that radiates to the left scapula. What do these findings best indicate? A) Hepatitis B B) Hepatic Encephalopathy C) Cholecystitis D) Pancreatitis

C) Cholecystitis

The nurse is caring for a client about to undergo a Tensilon test. What response best indicates the client is experiencing a mysthathenic crisis? A) Decreased force of cough B) Pupillary mydriasis C) Decreased ptosis D) Increased respiratory distress

C) Decreased ptosis

The nurse is caring for a 24-year-old female newly diagnosed with multiple sclerosis (MS). Which of the following should be included in the teaching plan? A) Pregnancy is not possible due to infertility B) Many women experience worsening symptoms during pregnancy C) Many women experience an improvement in symptoms during pregnancy D) Pregnancy should be avoided due to possible fetal death

C) Many women experience an improvement in symptoms during pregnanc

A nurse is caring for a client with rapidly progressing Guillain - Barre' Syndrome. What is the priority nursing intervention for this client? A) Pacing the client in isolation B) Preparing for plasmapheresis C) Monitoring respiratory status D) Monitoring renal status

C) Monitoring respiratory status

The nurse has received report on a client with Glasgow Coma Scale score below. When assessing the client, the nurse expects what finding? Eye opening 3 Verbal 4 Motor 5 A) The client will make no attempt to vocalize B) The client will be unconscious C) The client is able to open eye on command D) The client will be able to obey commands by showing two fingers

C) The client is able to open eye on command

The nurse is caring for a client admitted to the hospital with Guillain - Barre' syndrome. What should the nurse know about the acute phase of Guillain - Barre' syndrome? A) Although voluntary motor neurons are damaged by the inflammatory response, the automatic nervous system is unaffected by the disease B) The most serious complication of this condition is ascending demyelination of the peripheral nerves and the cranial nerves C) The most important aspect of care is to monitor the client's respiratory rate and depth and vital capacity D) Early treatment with corticosteroids can suppressed the immune response and prevent ascending nerve damage

C) The most important aspect of care is to monitor the client's respiratory rate and depth and vital capacity

The nurse is preparing to administer medications to the following clients. Which client should receive their medication first? A) The narcotic pain medication to a client with a closed head injury B) The morning medications for the spinal cord injury client going to physical therapy C) The osmotic diuretic to the client with a closed head injury D) The anticonvulsant to the client with leg syndrome

C) The osmotic diuretic to the client with a closed head injury

The nurse has completed discharge teaching for a client with seizures. What statement by the family member indicates teaching has been successful? A) "I will give diazepam intravenously during tonic-colonic seizure" B) "I will give diazepam sublingually during a tonic-colonic seizure" C)" I will give diazepam recital during a tonic-colonic seizure" D) "I will give diazepam intramuscularly during a tonic-colonic seizure"

C)" I will give diazepam recital during a tonic-colonic seizure

The nurse is caring for a client who experienced C7 cord transection 10 days ago. During the care of the patient he states "I am not sure that I can do this. I am not sure I want to do this." The first response by the nurse should be: A. "Of course you can do this!" B. "Why do you think that you can't do this?" C. "Have you been thinking of hurting yourself?" D. "With good rehabilitation, you can have a great life.

C. "Have you been thinking of hurting yourself?"

The nurse is caring for a client newly diagnosed with Multiple Sclerosis. The nurse begins the client on a course of immunomodulating medication. What statement by the nurse demonstrates an understanding of this? A. "This medication is expected to cure your disease if taken correctly." B. "This medication is to prevent you developing cancer along with Multiple Sclerosis." C. "This medication is most effective when begun early in the disease process." D. "This medication is given to all patient with Multiple Sclerosis for exacerbations."

C. "This medication is most effective when begun early in the disease process."

The nurse is caring for a client in the postictal phase. What is the priority nursing intervention? A. Reorient the client to time, place and person. B. Determine the client's level of consciousness. C. Assess the client's airway. D. Position the client comfortably.

C. Assess the client's airway.

The nurse is caring for a client with Guillain-Barre Syndrome. What laboratory result would support the client's diagnosis? A. Serum WBC: 5.8 10%/L B. Serum Glucose: 75mg/dL C. CSF Protein: Positive D. Serum Potassium: 3.5 mmol/L

C. CSF Protein: Positive

The nurse is preparing to teach a client with systemic lupus erythematosus. What information should the nurse include in the teaching plan? A. It is a hereditary disorder that is most commonly diagnosed when a woman is pregnant. B. The disease is progressive and occurs only in women in which there is an inadequate acetylcholine response. C. It is an inflammatory disease that is the result of an unpredictable and dysfunctional immune system. D. The disease produces antibodies that bind to estrogen receptor sites, causing an inflammatory response.

C. It is an inflammatory disease that is the result of an unpredictable and dysfunctional immune system.

The nurse is caring for a client with a cervical spinal cord injury. What interventions should be implemented? Select all that apply. A. Remove the C-Collar while in bed to prevent skin breakdown B. Maintain the client in high-fowler's position at all times C. Place sequential compression devices on the client D. Utilize additional staff to stabilize spine during repositioning E. Cluster care 4 times a day to avoid overstimulating the client

C. Place sequential compression devices on the client D. Utilize additional staff to stabilize spine during repositioning

The registered nurse (RN) is making assignments for the day. What tasks may be delegated to a unlicensed assistive personnel (UAP)? A. Perform discharge teaching for a client with seizures. B. Develop a plan of care for newly admitted client with seizures. C. Remove potentially harmful objects from the bedside and pad side rails. D. Assess the phenytoin level of client with seizures.

C. Remove potentially harmful objects from the bedside and pad side rails.

The nurse is caring for a client diagnosed with multiple sclerosis (MS) who is experiencing severe muscle fatigue with weakness and ataxia. What nursing intervention will best decrease a major complication associated with immobility? A. Turn the client every 4 hours to prevent pressure ulcers. B. Administer a muscle relaxant to reduce spasticity. C. Use of incentive spirometry, coughing and deep breathing every 2 hours. D. Have the client wear high-top tennis shoes while in bed to prevent foot-drop.

C. Use of incentive spirometry, coughing and deep breathing every 2 hours.

The nurse is assessing the perineal wound in a client who has returned from the operating room following an abdominal perineal resection and notes serosanguineous drainage from the wound. Which nursing intervention is most appropriate? 1. Clamp the surgical drain. 2. Change the dressing as prescribed. 3. Notify the surgeon. 4. Remove and replace the perineal packing.

Change the dressing as prescribed. Rationale: Immediately after surgery, profuse serosanguineous drainage from the perineal wound is expected. Therefore, the nurse should change the dressing as prescribed. A surgical drain should not be clamped, because this action will cause the accumulation of drainage within the tissue. The nurse does not need to notify the surgeon at this time. Drains and packing are removed gradually over a period of 5 to 7 days as prescribed. The nurse should not remove the perineal packing

A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take? A. Have the patient gently blow the nose. B. Check the drainage for glucose content. C. Teach the patient that rhinorrhea is expected after a head injury. D. Obtain a specimen of the fluid to send for culture and sensitivity.

Check the drainage for glucose content. Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.

T1 SCI

Client are will be retained

To reduce the risk for falls in the patient with Parkinson's disease, what is the best thing the nurse should teach the patient to do? a. Use an elevated toilet seat. b. Use a wheelchair for mobility. c. Use a walker or cane for support. d. Consciously think about stepping over an imaginary object.

Consciously think about stepping over an imaginary object. The shuffling gait of PD causes the patient to be off balance and at risk for falling. A more balanced gait can be promoted by teaching the patient to use a wide stance with the feet apart, to consciously think about stepping over an imaginary object when walking, and to look ahead. Use of an elevated toilet seat will enable a patient to initiate movement but not prevent falls. Using a wheelchair will not maintain independence or optimize psychosocial well-being. Canes and walkers are hard for the patient with PD to maneuver and may increase the risk for injury.

The nurse is caring for a patient who is scheduled for a paracentesis. What statement by the client indicates a need for further teaching? A) "The fluid contributes to shortness of breath" B) "A needle will be used to withdraw fluid" C) "My pain should be easier after the procedure D) "The procedure will prevent my ascites for re-occurring"

D) "The procedure will prevent my ascites for re-occurring"

The registered nurse (RN) is making assignments for the day. Which of the following tasks may be delegated to a licensed vocational nurse (LVN)? A) Assess the phenytoin level of client with seizures B) Perform discharge teaching for a client with seizures C) Develop a plan of care for newly admitted client with seizures D) Administer prescribed anticonvulsant medication to a client with seizures

D) Administer prescribed anticonvulsant medication to a client with seizures

The nurse is performing an assessment of a client with a C3 spinal cord injury that occurred three days ago. Based on this information, what is the priority for this client? Blood Pressure 188/98 mmHg Heart Rate 56 bpm Flushed skin present Diaphoresis present A) Notify the health care provider of heart rate B) Lower the head of the bed C) Administer the prescribed IV fluids D) Administer prescribed antihypertensive

D) Administer prescribed antihypertensive

The nurse is discussing risk factors with a client diagnosed with systemic lupus erythematosus (SLE). Who is most at risk for developing the disease? A) A fifty-year-old white female with diabetes mellites B) A sixty-year-old make with hypertension with a headache C) A fifteen-year-old boy with asthma who complains mid shortness of breath D) An African-American 30-year-old female who just delivered a baby

D) An African-American 30-year-old female who just delivered a baby

A client with Parkinson's disease asks the nurse why are they taking the drug levodopa/carbidopa. What is the best response? A) Levodopa alone cannot cross the blood-brain barrier, carbidopa required B) Carvadopa is used for short term treatment of severe symptoms. Levodopa must be added for long term use C) Levodopa alone has more significant drug food interactions than levodopa with carbidopa D) Carbidopa allows the brain to utilize the levodopa more efficiently with less breakdown

D) Carbidopa allows the brain to utilize the levodopa more efficiently with less breakdown

What information will the nurse include while teaching a client with multiple sclerosis (MS)? A) MS is caused by antidotes that are produced against acetylcholine receptors and result in blocked muscle contraction B) MS is a congenitally acquired illness and causes neurologic exacerbations and remissions C) MS is caused by impulses traveling too fast over nerves that have lost their myelin sheath D) MS is the result of an autoimmune process causing demyelination and the development

D) MS is the result of an autoimmune process causing demyelination and the development

The nurse is assessing a client recently diagnosed with hepatitis C. What findings are expected on the initial assessment? A) Cirrhosis and jaundice B) Left upper quadrant discomfort C) Dark stools and right upper quadrant discomfort D) Malaise and weight loss

D) Malaise and weight loss

The nurse is caring for a client with advanced cirrhosis, ascites, and dependent edema in the lower extremities. What is the priority assessment for tracking fluid retention? A) Measuring the blood pressure every morning B) Checking the extremities for pitting edema ad comparing to baseline C) Auscultating the lung fields for crackles daily D) Performing daily weights with same amount of clothing

D) Performing daily weights with same amount of clothing

The nurse is caring for a client diagnosed with seizures. During the assessment, the client is staring and their lips are smacking. What is the most important nursing intervention? A) Give phenytoin IV B) Restrain the client so they won't be harmed C) Give lorazepam (Ativan) PO D) Record a description and the duration of the seizure

D) Record a description and the duration of the seizure

The nurse is caring for a client with a T-7 injury hospital day one and finds a loss of motor and sensory function of the lower extremities. The following day, the nurse finds sensory deficit has extended to the upper extremities. What is most likely cause for this change? A) Possible re-injury of unknown organ B) Lack of patient cooperation C) Inadequate previous assessment D) Secondary injury related to cord swelling

D) Secondary injury related to cord swelling

Parkinson's disease is referred to as an extrapyramidal syndrome because it manifests which of the following characteristics? A) Tremor and diarrhea B) Tremor and hypertension C) Tremor and somnolence D) Tremor and bradykinesia

D) Tremor and bradykinesia

The nurse is assessing a client with gallstones blocking the common bile duct. What assessment findings are expected? A) Low grade fever and hypernatremia B) Pallor and tachycardia C) Amber urine and afebrile D) Yellow sclera and clay colored stools

D) Yellow sclera and clay colored stools

The nurse is caring for a client who has multiple sclerosis (MS). The client reports diplopia and sensory changes. What statement by the nurse is appropriate? A. "Wear an eye patch on the right eye at all times." B. "Use hot and cold therapy when needed." C. "Participate in a vigorous exercise program." D."Include rest periods throughout the day."

D. "Include rest periods throughout the day."

The nurse has completed teaching about myasthenia gravis (MG). What statement best indicates teaching has been effective? A. "There is destruction of the myelin sheath and it is progressive in nature". B. "There is a rapid destruction of acetylcholine and the receptor sites". C. "The exacerbations and remissions are due to dopamine and acetylcholine availability" D. "There is decreased availability of acetylcholine receptor sites and exacerbations and remissions are common".

D. "There is decreased availability of acetylcholine receptor sites and exacerbations and remissions are common".

The nurse is caring for a client admitted with a traumatic brain injury two days ago. What signs and symptoms require immediate intervention? A. Tachycardia, ICP 12 mmHg, and elevated systolic blood pressure. B. Tachycardia, oral temperature 97.1 F, and elevated systolic blood pressure. C. Bradycardia, elevated diastolic blood pulse pressure, and ICP 13 mmHg. D. Bradycardia, elevated systolic blood pressure, and irregular respirations.

D. Bradycardia, elevated systolic blood pressure, and irregular respirations.

The nurse is caring for a client who fell and initially lost consciousness at the time of injury and then regained it. The client is now exhibiting signs of altered mental status. What condition is most likely the cause? A. Skull fracture. B. Concussion. C. Diffuse axonal injury. D. Epidural hematoma.

D. Epidural hematoma.

The nurse is caring for a client with a cervical fracture. What findings indicate the client may have spinal shock? A. Hypotension, bradycardia, and warm extremities. B. Involuntary, spastic movements of the arms and legs. C. The presence of hyperactive reflex activity below the level of the injury. D. Flaccid paralysis and lack of sensation below the level of the injury.

D. Flaccid paralysis and lack of sensation below the level of the injury

The nurse is caring for a client with a spinal cord injury at T3. The patient is 7 days post injury and suddenly develops a blood pressure of 88/52 mmHg. The nurse knows that the patient is demonstrating what complication of spinal cord injury. A. Spinal shock due to increased deep tendon and sphincter reflexes. B. Cardiogenic shock due to decrease cardiac output. C. Hypovolemic shock due to excessive blood loss during the injury. D. Neurogenic shock due to loss of sympathetic nervous system innervation.

D. Neurogenic shock due to loss of sympathetic nervous system innervation

The nurse is assessing a client who only responds to noxious stimuli all extremities and plantar flexion of the feet. What statement best indicates an understanding of these signs? A. There is a lesion of the cerebral cortex. B. The brainstem is completely nonfunctional. C. This is a normal response and will resolve in 24 to 48 hours. D. This is a very ominous sign and may indicate brainstem injury.

D. This is a very ominous sign and may indicate brainstem injury.

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how should the nurse report the response? A. Flexion withdrawal B. Localization of pain C. Decorticate posturing D. Decerebrate posturing

Decorticate posturing Internal rotation, adduction, and flexion of the arms in an unconscious patient is documented as decorticate posturing. Extension of the arms and legs is decerebrate posturing. Because the flexion is generalized, it does not indicate localization of pain or flexion withdrawal.

Which assessment finding is most indicative of Parkinson's disease? a. Large, embellished handwriting b. Weakness of one leg resulting in a limping walk c. Difficulty rising from a chair and beginning to walk d. Onset of muscle spasms occurring with voluntary movement

Difficulty rising from a chair and beginning to walk The akinesia of PD prevents automatic movements. Activities, such as beginning to walk, rising from a chair, or even swallowing saliva, cannot be executed unless they are consciously willed. Handwriting is affected by the tremor and results in the writing trailing off at the end of words. Specific limb weakness and muscle spasms are not characteristic of PD.

The nurse is admitting a client with Guillain-Barré syndrome to the nursing unit. The client has complaints of inability to move both legs and reports a tingling sensation above the waistline. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room? 1. Nebulizer and pulse oximeter 2. Blood pressure cuff and flashlight 3. Nasal cannula and incentive spirometer 4. Electrocardiographic monitoring electrodes and intubation tray

Electrocardiographic monitoring electrodes and intubation tray Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure because of ascending paralysis. An intubation tray should be available for use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the use of electrocardiographic monitoring. Because the client is immobilized, the nurse should assess for deep vein thrombosis and pulmonary embolism routinely. Although items in the incorrect options may be used in care, they are not the most essential items from the options provided.

Person with MS fatigued from activity?

Encourage pt. to cluster activities with frequent rest periods

What should the nurse explain to the patient who has a T2 spinal cord transection injury? A. Total loss of respiratory function may occur. B. Function of both arms should be maintained. C. Use of the patient's shoulders will be limited. D. Tachycardia is common with this type of injury.

Function of both arms should be maintained. The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

Automonic dysreflexia

HOB 45

During the patient's process of grieving for the losses resulting from SCI, what should the nurse do? a. Help the patient understand that working through the grief will be a lifelong process. b. Assist the patient to move through all stages of the mourning and grief process to acceptance. c. Let the patient know that anger directed at the staff or the family is not a positive coping mechanism. d. Facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation.

Help the patient understand that working through the grief will be a lifelong process. Working through grief is a lifelong process. It is triggered by new experiences, such as marriage, child rearing, employment, or illness, to which the patient must adjust throughout life within the context of their disability. The goal of recovery is related to adjustment rather than complete acceptance, and many patients do not experience all components of the grief process. During the anger phase, the patient should be allowed outbursts. The nurse may use humor to displace some of the patient's anger.

The nurse is admitting a patient who has a neck fracture at the C6 level to the intensive care unit. Which finding on the nursing assessment is congruent with neurogenic shock? A. Involuntary and spastic movement B. Hypotension and warm extremities C. Hyperactive reflexes below the injury D. Lack of sensation or movement below the injury

Hypotension and warm extremities Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury but not neurogenic shock.

SLE teaching

I will avoid with infections, fatigue, and over exposure to the sun

Chart given🡪

IV fluid at rate ..

Cholelithiasis first intervention🡪

IV morphine

Nurse teaching patient with SLE when to see a doctor?

If pt. develops a fever, rash, weight loss, fatigue

Hep A antibodies

IgM = in the moment the pt has it IgG = its gone (past)

Carbidopa-levodopa is prescribed for a client with Parkinson's disease. The nurse monitors the client for side and adverse effects of the medication. Which finding indicates that the client is experiencing an adverse effect? 1. Pruritus 2. Tachycardia 3. Hypertension 4. Impaired voluntary movements

Impaired voluntary movements Rationale: Dyskinesia and impaired voluntary movements may occur with high carbidopa-levodopa dosages. Nausea, anorexia, dizziness, orthostatic hypotension, bradycardia, and akinesia are frequent side effects of the medication.

The nurse is caring for a client C5 spinal cord injury who has a halo vest in place. Based on the data below, what is the priority of care? Blood Pressure: 82/54 mmHg Heart Rate:55 bpm Respirations: 22 per minute Temperature: 98.9 degrees F Oxygen Saturation: 97% on room air Pain: 8/10 A) Normalizing the client's temperature B) Improving the client's circulation C) Controlling the client's pain

Improving the client's circulation

A patient hospitalized with a new diagnosis of Guillain-Barré syndrome has numbness and weakness of both feet. Which intervention should the nurse anticipate? A. Infusion of immunoglobulin B. Administration of corticosteroids C. Intubation and mechanical ventilation D. Insertion of a nasogastric (NG) feeding tube

Infusion of immunoglobulin Because Guillain-Barré syndrome is in the earliest stages (as evidenced by the symptoms), use of high-dose immunoglobulin is appropriate to reduce the extent and length of symptoms. Mechanical ventilation and enteral nutrition may be used later in the progression of the syndrome but are not needed now. Corticosteroids are not helpful in reducing the duration or symptoms of the syndrome.

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

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

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter should the nurse monitor to determine the medication's effectiveness? A. Blood pressure B. Oxygen saturation C. Intracranial pressure D. Hemoglobin and hematocrit

Intracranial pressure Mannitol is an osmotic diuretic and will reduce cerebral edema and intracranial pressure. It may initially reduce hematocrit and increase blood pressure, but these are not the best parameters for evaluation of the effectiveness of the drug. O2 saturation will not directly improve because of mannitol administration.

A patient with Parkinson's disease is started on levodopa. What should the nurse teach the patient about this drug? a. It stimulates dopamine receptors in the basal ganglia. b. It promotes the release of dopamine from brain neurons. c. It is a precursor of dopamine that is converted to dopamine in the brain. d. It prevents the excessive breakdown of dopamine in the peripheral tissues.

It is a precursor of dopamine that is converted to dopamine in the brain. Peripheral dopamine does not cross the blood-brain barrier. However, its precursor levodopa is able to enter the brain, where it is converted to dopamine, increasing the supply that is deficient in PD. Bromocriptine is used to treat PD to stimulate dopamine receptors in the basal ganglia. Amantadine stimulates dopamine release and blocks the reuptake of dopamine into presynaptic neurons. Carbidopa and entacapone are usually given with levodopa to prevent the levodopa from being metabolized in peripheral tissues before it can reach the brain.

Priority Decision: During care of a patient in myasthenic crisis, what should be the nurse's first priority for the patient? a. Maintaining mobility b. Adequate nutrition c. Maintaining respiratory function d. Maintaining verbal communication

Maintaining respiratory function The patient in myasthenic crisis has severe weakness and fatigue of all skeletal muscles, affecting the patient's ability to breathe, swallow, talk, and move. However, the priority of nursing care is monitoring and maintaining adequate respiratory function.

The nurse has completed teaching for a client newly diagnosed with Parkinson disease. What statement by the client indicates the needing for further discussion?

Many changes found in the brains of people with PD may play a part in development of the disea a lack of DA. The pathologic process of PD involves degeneration of the DA-producing neurons i substantia nigra of the midbrain. This in turn disrupts the normal balance between DA and acety (ACh) in the basal ganglia. The neurotransmitter DA is essential for normal functioning of the ex motor system, including control of posture, support, and voluntary motion. Lewis, 11th Ed. pg. 1

Hep A s/s 🡪

Mild flu-like , jaundice, acute liver failure,

Patient has low platelet counts in the questions, what should you look for?

Monitor for blood in the stool

. Patient in the ICU with GB syndrome, what should the nurse monitor?

Monitor forced vital capacity and negative inspiratory force

During assessment of a patient admitted to the hospital with an acute exacerbation of MS, what should the nurse expect to find? a. Tremors, dysphasia, and ptosis b. Bowel and bladder incontinence and loss of memory c. Motor impairment, visual disturbances, and paresthesias d. Excessive involuntary movements, hearing loss, and ataxia

Motor impairment, visual disturbances, and paresthesias Specific neurologic dysfunction of MS is caused by destruction of myelin and replacement with glial scar tissue at specific areas in the nervous system. Motor, sensory, cerebellar, and emotional dysfunctions, including paresthesia, patchy blindness, blurred vision, pain radiating along the dermatome of the nerve, ataxia, and severe fatigue, are the most common manifestations of MS. Constipation and bladder dysfunction, short-term memory loss, sexual dysfunction, anger, and depression or euphoria may occur. Excess involuntary movements and tremors are not seen in MS.

The classic manifestations associated with Parkinson's disease are tremor, rigidity, akinesia, and postural instability. What is a consequence related to rigidity? a. Shuffling gait b. Impaired handwriting c. Lack of postural stability d. Muscle soreness and pain

Muscle soreness and pain The degeneration of dopamine-producing neurons in the substantia nigra of midbrain and basal ganglia lead to these signs. Muscle soreness, pain, and slowness of movement are consequences of patient function related to rigidity. Shuffling gait, absent arm swing while walking, absent blinking, masked facial expression, saliva drooling, and difficulty initiating movement are all related to akinesia. Impaired handwriting and hand activities are related to the tremor of Parkinson's disease (PD). Being unable to stop the self from going forward or backward results from postural instability.

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

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

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

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

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

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

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

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

A patient with MS is having difficulty with hygienic care due to muscle spasticity and neuromuscular deficits. In providing care for the patient, what is most important for the nurse to do? a. Teach the family members how to care adequately for the patient's needs. b. Encourage the patient to maintain social interactions to prevent social isolation. c. Promote the use of assistive devices so that the patient can take part in self-care activities.

Promote the use of assistive devices so that the patient can take part in self-care activities The main goals in care of the patient with MS is to keep the patient active and maximally functional, and promote self-care as much as possible to maintain independence. Assistive devices encourage independence while preserving the patient's energy. No care activity should be done by others if the patient can do it for himself or herself. Family involvement in the patient's care and maintaining social interactions are important but not the priority.

What should the nurse include in a rehabilitation plan as an appropriate goal for a 30-yr-old patient with a C6 spinal cord injury? A. Drive a car with powered hand controls. B. Propel a manual wheelchair on a flat surface. C. Turn and reposition independently when in bed. D. Transfer independently to and from a wheelchair

Propel a manual wheelchair on a flat surface. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

A client with Guillain-Barré syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which strategy should the nurse incorporate in the plan of care to help the client cope with this illness? 1. Giving client full control over care decisions and restricting visitors 2. Providing positive feedback and encouraging active range of motion 3. Providing information, giving positive feedback, and encouraging relaxation 4. Providing intravenously administered sedatives, reducing distractions, and limiting visitors

Providing information, giving positive feedback, and encouraging relaxation Rationale: The client with Guillain-Barré syndrome experiences fear and anxiety from the ascending paralysis and sudden onset of the disorder. The nurse can alleviate these fears by providing accurate information about the client's condition, giving expert care and positive feedback to the client, and encouraging relaxation and distraction. The family can become involved with selected care activities and provide diversion for the client as well.

The nurse is caring for a client with ICP of 24 and MAP 62 . Based on the client's CPP, what is the FIRST intervention?

Raise HOB of the bed 30 degrees

A patient with a tremor is being evaluated for Parkinson's disease. What would the nurse explain to the patient can confirm the diagnosis of Parkinson's disease? a. CT and MRI scans. b. Relief of symptoms with administration of dopaminergic agents. c. The presence of tremors that increase during voluntary movement. d. Cerebral angiogram that reveals the presence of cerebral atherosclerosis.

Relief of symptoms with administration of dopaminergic agents. Although clinical manifestations are characteristic in PD, no laboratory or diagnostic tests are specific for the condition. A diagnosis is made when the presence of tremor, rigidity, akinesia, and postural instability occur with asymmetric onset. It is confirmed with a positive response to antiparkinsonian drugs. Research about the role of genetic testing and MRI to diagnose PD is ongoing. Essential tremors increase during voluntary movement, while the tremors of PD are more prominent at rest.

The nurse is caring for a patient with systemic lupus erythematosus. What is the most likely complication?

Renal insufficiency About 75% of persons with SLE experience kidney damage. Renal involvement is usually evident within the first 2 years after diagnosis. 3 Manifestations of renal involvement vary from mild proteinuria to rapidly progressive glomerulonephritis. Scarring and permanent damage can lead to end-stage renal disease (ESRD).

1. A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action should the nurse take first? A. Document the BP and ICP in the patient's record. B. Report the BP and ICP to the health care provider. C. Elevate the head of the patient's bed to 60 degrees. D. Continue to monitor the patient's vital signs and ICP.

Report the BP and ICP to the health care provider. Calculate the cerebral perfusion pressure (CPP): (CPP = Mean arterial pressure [MAP] ?2- ICP). MAP = DBP + 1/3 (Systolic blood pressure [SBP] ?2- Diastolic blood pressure [DBP]). Therefore, the MAP is 70, and the CPP is 56 mm Hg, which are below the normal values of 60 to 100 mm Hg and are approaching the level of ischemia and neuronal death. Immediate changes in the patient's therapy such as fluid infusion or vasopressor administration are needed to improve the CPP. Adjustments in the head elevation should only be done after consulting with the health care provider. Continued monitoring and documentation will also be done, but they are not the first actions that the nurse should take.

Priority Decision: The patient was in a traffic collision and has loss of function below C4. Which effect most influences how the nurse prioritizes care? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the sympathetic nervous system d. Gastrointestinal (GI) hypomotility with paralytic ileus and gastric distention

Respiratory diaphragmatic breathing SCI below C4 will result in diaphragmatic breathing and usually hypoventilation from decreased vital capacity and tidal volume from intercostal muscle impairment. The nurse's priority actions will be to monitor rate, rhythm, depth, and effort of breathing to observe for changes from the baseline and identify the need for ventilation assistance. Loss of all respiratory muscle function occurs above C4, and the patient needs mechanical ventilation to survive.

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

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

The client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome. Which past medical history finding makes the client most at risk for this disease? 1. Meningitis or encephalitis during the last 5 years 2. Seizures or trauma to the brain within the last year 3. Back injury or trauma to the spinal cord during the last 2 years 4. Respiratory or gastrointestinal infection during the previous month

Respiratory or gastrointestinal infection during the previous month Rationale: Guillain-Barré syndrome is a clinical syndrome of unknown origin that involves cranial and peripheral nerves. Many clients report a history of respiratory or gastrointestinal infection in the 1 to 4 weeks before the onset of neurological deficits. On occasion, the syndrome can be triggered by vaccination or surgery.

The nursing is caring for a client with a basilar skull fracture. What assessment findings would the nurse expect? SATA

Rhinorrhea, Battle's sign, Vertigo

The nurse is caring for a client admitted with a brain tumor. When the client has signs of increased intracranial pressure (ICP), what priority nursing intervention will keep the patient from injury? A. Reality orientation B. Seizure precautions C. 4-point restraints D. Decreased environmental stimuli

Seizure precautions

A patient with myasthenia gravis is admitted to the hospital with respiratory insufficiency and severe weakness. What should the nurse recognize will confirm a diagnosis of myasthenia gravis? a. History and physical examination reveal weakness. b. Serum acetylcholine receptor antibodies are present. c. The patient's respiratory function is impaired because of muscle weakness. d. EMG reveals an increased response with repeated stimulation of muscles.

Serum acetylcholine receptor antibodies are present. Serum acetylcholine receptor antibodies will confirm a diagnosis of myasthenia gravis (MG). The history and physical revealing weakness is part of the diagnosis, but not the confirmation. Impaired respiratory function is a sign of MG, but not a confirmation of the diagnosis. The EMG will show muscle fatigue with a decreased response.

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

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

The nurse is teaching a client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. Which client activity suggests that teaching is most effective? 1. Taking medications as scheduled 2. Eating large, well-balanced meals 3. Doing muscle-strengthening exercises 4. Doing all chores early in the day while less fatigued

Taking medications as scheduled Rationale: Clients with myasthenia gravis are taught to space out activities over the day to conserve energy and restore muscle strength. Taking medications correctly to maintain blood levels that are not too low or too high is important. Muscle-strengthening exercises are not helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is exposure to heat, crowds, erratic sleep habits, and emotional stress.

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

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

Person with PD who coughed while eating?

Tell patient to tuck chin

A 70-year-old patient is admitted after falling from his roof. He has an SCI at the C7 level. What assessment findings would indicate the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation

Tetraplegia with total sensory loss At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with flaccid paralysis would occur at the level of T1 or below. Hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

Which assessment data for a patient who has Guillain-Barré syndrome will require the nurse's most immediate action? A. The patient's sacral area skin is reddened. B. The patient reports severe pain in the feet. C. The patient is continuously drooling saliva. D. The patient's blood pressure (BP) is 150/82 mm Hg.

The patient is continuously drooling saliva. Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, the BP requires ongoing monitoring, and the skin integrity requires intervention, but these actions are not as urgently needed as maintenance of respiratory function.

The nurse is creating a teaching plan for a patient with Gullain-Barre' Syndrome. What is the best information to teach the client? A) The syndrome is progressive and eventually fatal B) The syndrome effects only lower extremities and cranial nerves I, II, and III C) The syndrome is characterized by exacerbations and remissions D) The syndrome is usually rapid and involves the immune system

The syndrome is usually rapid and involves the immune system

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

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

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

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

The nurse is caring for a client diagnosed with multiple sclerosis (MS) who experiencing severe muscle fatigue with weakness and ataxia. What nursing intervention will best decrease a major complication associated with immobility?

Use of incentive spirometry coughing and deep breathing very 2 hours. Rationale: During an acute exacerbation, the client may be immobile and confined to bed. The focus nursing intervention at this time is to prevent major complications of immobility such as, respiratory and UTI and pressure ulcers. Death usually occurs due to complication of immobility. Lewis page 1367 - 1371

SCI SATA

Utilize additional steps to stabilize during repositioning

The nurse is caring for a client with a basilar skull fracture. What assessment findings would the nurse expect? SATA A. Vertigo B. Decreased blood pressure C. Battle's sign D. Rhinorrhea E. Increased pulse

Vertigo Battle's sign Rhinorrhea

The nurse is caring for a client experiencing status epilepticus. Which of the following is priority treatment for this condition? a. Admin lorazepam b. Admin phenobarbital c. Admin phenytoin d. Begin conscious sedation

a. Admin lorazepam

The nurse is caring for a client with end stage liver failure. What factors can contribute to the development of cirrhosis? SATA a. Alcoholism b. Smoking c. Hepatitis C d. Acetaminophen e. Hypotension

a. Alcoholism c. Hepatitis C d. Acetaminophen

The nurse is caring for a client in neurogenic shock. What symptoms will the nurse expect to see? SATA a. BP < 89 mmHg b. HR 55 c. Decrease cardiac output d. Flaccid paralysis e. Loss of sensation

a. BP < 89 mmHg b. HR 55 c. Decrease cardiac output

A nurse is assessing a clinet with Parkinson's disease. The nurse expects to see what clinical presentation when observing muscle movements. Select all that apply. a. Loss of voluntary muscle control b. Slowness of movement c. Shuffling gait d. Paralysis of muscles of respiration e. Uncontrolled backward motion

a. Loss of voluntary muscle control b. Slowness of movement c. Shuffling gait e. Uncontrolled backward motion

The nurse is assessing a client with hepatic encephalopathy and notices a flapping motion of the hands. What is the most likely cause of this clinical manifestation? a. The client has an increased ammonia b. The client has an increased sodium c. The client has a decreased albumin

a. The client has an increased ammonia

The nurse is caring for a client admitted to the hospital with Guillain-Barré syndrome. What priority information should the nurse consider in their plan of care? a. The most important aspect of care is to monitor the client's respiratory rate and depth and vital capacity. b. Early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage. c. The most serious complication of this condition is pain that is difficult to manage and worse in the day when the patient is awake d. Although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease.

a. The most important aspect of care is to monitor the client's respiratory rate and depth and vital capacity.

Pt says "I can't do this, I don't want to" 🡪

are you thinking of hurting or killing yourself?

The nurse is caring for a client with a T-7 injury hospital day one and finds a loss of motor and sensory function of the lower extremities. The following day, the nurse finds the sensory deficit has extended to the upper extremities. What is the most likely cause for this change? a. Inadequate pervious assessment b. Inflammatory response related to cord injury c. Possible re-injury of unknown origin d.Lack of patient cooperation during assessment

b. Inflammatory response related to cord injury

The nurse is assessing a client with Parkinson's disease. What assessment finding is expected? a. Loss of control b. Repetitive circular movement of the fingers c. Red-green color distortion of vision d. Ptosis of the eyelids

b. Repetitive circular movement of the fingers

The nurse is caring for a client with esophageal varices. When providing care, what is the priority nursing action? a. Admin IV vit K b. Stabilize and manage airway c. Infuse 1 unit of PBRCs d. Insert nasogastric NG tube

b. Stabilize and manage airway

Basilar skull fracture (SATA)🡪

battle sign, racoon sign, rhinorrhea

Hep A🡪

boiled water consumed and cook smth

The nurse is caring for a client with a C-5 injury, will manifest the following signs of neurogenic shock: SATA

bradycardia & hypotension

Neurogenic shock (SATA)🡪

bradycardia, hypotension

Parkinson's S/S:

bradykinesia and (tremors or rigidity)

A client diagnosed with a spinal cord injury after a fall experiences diaphoresis, headache, and his blood pressure is 152/104 mmHg. Which response should the nurse perform first? a. Admin antihypertensive medication and place the client on telemetry b. Assess the client for fecal impaction c. Raise the head of the bed, lower the legs, and remove restrictive clothing d. Place an IV and admin normal saline bolus

c. Raise the head of the bed, lower the legs, and remove restrictive clothing

The nurse is caring for a client admitted to the hospital with a diagnosis of hep B. What is the best way to prevent the spread of this infection? a. Respiratory precautions b. Enteric precautions c. Standard precautions d. Contact precautions

c. Standard precautions

BP taken on patient, hand cramp🡪

check chemistry level

GBS highest risk

client taking abx for GI

What group should the nurse target when planning community education on preventing spinal cord injuries (SCIs)? a. Older men b. Teenage girls c. Elementary school-age children d. Adolescent and young adult men

d. Adolescent and young adult men Young adult men ages 16 to 30 years, who may be impulsive or risk takers in daily living, have the greatest risk for spinal cord injury (SCI). Other risk factors include alcohol and drug use, taking part in sports, and occupational exposure to trauma or violence.

A nurse is caring for a client with a spinal cord injury. What intervention is most appropriate to promote skin health for this client? a. Avoid use of lotions or creams on skin b. Minimize the use of a wheelchair whenever possible c. Turn the client while in bed every three to four hours d. Encourage repositioning every 15-20 mins in wheelchair

d. Encourage repositioning every 15-20 mins in wheelchair

The nurse is caring for a client who is scheduled for a paracentesis. To decrease the risk of an adverse event, what pre-procedure care will the nurse provide? a. Admin IV fluid and sodium bicarbonate b. Obtain clients signature on consent form c. Provide incentive spirometry d. Have the client empty their bladder

d. Have the client empty their bladder

The nurse is caring for a client diagnosed with seizures. During the assessment, the client is staring off into space and not responding to questions. What is the priority action? a. Lay the client flat to prevent injury b. Admin Lorazepam 2 mg STAT c. Place the nonrebreather mask on the client d. Note the time the seizure activity started

d. Note the time the seizure activity started

The nurse is caring for a client with new-onset seizures. While at the bedside, the client begins seizing. What is the priority action? a. Call the rapid response team b. Hold the patient down to prevent injury c. Insert an oral airway and call for help d. Roll client to the right side and protect the airway

d. Roll client to the right side and protect the airway

Noncompliance of HIV meds🡪

do not understand the reason for taking antiviral therapy

ICP

elevate hob & neck and head midline

SATA regarding All symptoms

everything BUT bone pain and weight gain

Patient used lactulose, nursing intervention-🡪

fall/injury prevention

Spinal shock🡪

flaccid paralysis and loss of sensation below level of injury

Parkinson's disease

gait shuffling (Dopamine)

Person comes in complaining of confusion

gather more data and assess

cholinergic effect

give atropin

Patient Priority-🡪

go see the patient with 4 seizures in 30 min first

The nurse should explain to a patient newly diagnosed with MS that the diagnosis is made primarily by a. spinal x-ray findings. b. T-cell analysis of the blood. c. analysis of cerebrospinal fluid. d. history and clinical manifestations.

history and clinical manifestations. There is no specific diagnostic test for MS. A diagnosis is made primarily by history and clinical manifestations. Certain diagnostic tests may be used to help establish a diagnosis of MS. Positive findings on MRI include evidence of at least 2 inflammatory demyelinating lesions in at least 2 different locations within the central nervous system (CNS). Cerebrospinal fluid (CSF) may have increased immunoglobulin G and the presence of oligoclonal banding. Evoked potential responses are often delayed in persons with MS.

Phenytoin med:

hold the med

Ascites🡪

hypoalbuminemia, hyperaldosterone, portal HTn

Cholinergic crisis SATA, what are the S/S observed:

increased perspiration and

Patient asks why they are taking the combo drug carbidopa/levodopa (sinemit)

increases dopamine. it's the only question that says Sinemet and talks about increasing dopamine needed for the body

Gall bladder with nausea, vomiting🡪

lactate ringer 500 over 30 min

Phenotyne

level 10 - 20

SATA🡪

lumbar puncture, MRI, CT

Esophageal varices🡪

maintain airway

Pt at home, family doing most of the ADL, best RN response🡪

make plan of care that involve patient independence with family included

HIV patient non-compliance🡪

need to take multiple medication

Patient having tonic-clonic seizure on the way to ED-🡪

observe time, record detail of seizure and postictal state

HCP risk for Hep B, what is the prevention measure🡪

obtain vaccine/ immunization

Glasgow coma scale🡪

open eye to command

1. Yellow-bluish discoloration of periumbilical area in which disease🡪

pancreatitis

GSC # UNDER 8

prepare for intubation

Person with GB

progressive ascending paralysis

Tension test- how would you know if it is a myasthenic crisis

ptosis decreases

ICP intervention🡪

raise HOB

Diazepam at home, how to take🡪

rectally

Brain tumor patient ask about the treatment🡪

reduce the size or remove the tumor will be recommended

Patient with SCI regain sensation after few month🡪

resolution of spinal shock

Patient with seizure, nurse wants to give Lorazepam, assessment that warrant immediate intervention 🡪

respiration 8 breaths per min

Pancreatitis pt pain location🡪

right upper quadrant and right scapula

AIDS dementia patient intervention🡪

risk for fall

Priority ICP brain tumor

seizure precaution

Most recent cause of HIV these days🡪

sex with infected partner

Wasting syndrome🡪

sit them upright and limit food they cannot tolerate

1. RN need to correct NPA🡪

slightly restricting pt. upper extremities having seizures

Hep A txt (SATA)🡪

small meals, adequate rest, one more

. Teaching regarding patho of MG

something regarding decreased acetylcholine receptors

Head injury s/s(SATA)🡪

sudden onset of HA, nausea, ipsilateral pupils

ICP pt concern🡪

temperature 100.9

Hepatic encephalopathy🡪

tremor of hand when extended

Seizure

turn pt on left side

1. Nurse on bed side, pt start seizing, priority🡪

turn the patient on side and protect the airway

epidural hematoma

unconscious and regains conscious

MS fatigue & weakness, best intervention to avoid complication

use SI

Early signs for MS:

vision changes and fatigue

Decerebrate patient getting better sign🡪

withdraw from pain

Delegation to LVN/LPN🡪

wound drainage....dressing change every 6 hour

Bile duct obstruct🡪

yellow sclera and clay colored stool