MCA II Exam 4

Which client statement indicates that the instructions to a client with a seizure disorder receiving phenytoin and phenoabarbital are understood? A. I will not have any seizures on this medication B. These medicines must be continued to prevent falls and injury C. Stopping the medications can cause continuous seizures and I may die D. By staying on the medications I will prevent postseizure confusion

C. Stopping the medications can cause continuous seizures and I may die combination therapy suggests that this client has seizures that are difficult to control. sudden withdrawal of any antiepileptic medication can cause onset of frequent seizures or even status epilepticus. death can occur if seizures are continuous due to a lack of adequate oxygenation and cardiac irregularities. it is important to take medication as prescribed to lessen the frequency of seizures; there is no guarantee that seizures will stop. antiepileptic medications are not prescribed to prevent falls and injury and the added central nervous system (CNS) depression increases fall risk. although seizures may occur while the client is taking the medications, the medications do not stop post-seizure confusion.

Which clinical manifestation are found in the client diagnosed with stage 3 Parkinson Disease? Select all that apply A. Akinesia B. Mask-like face C. Postural Instability D. Unilateral limb involvement E. Increased gait disturbances

B, C, E Parkinson disease is a progressive neurodegenerative disease that is one of the most common neurological disorders of older adults. stage 3 of Parkinson disease is characterized by postural instability and increased gait disturbances. the "masklike" face begins in stage 2 and continues in stage 3. akinesia is manifested in stage 4 of the disease. in stage 1 of Parkinson disease, only unilateral limb involvement is seen, but it progresses to bilateral in later stages.

which action would the nurse anticipate when admitting a client having a sickle cell crisis to the nursing unit? select all that apply a. place on strict isolation b. administer hydroxyurea c. administer aspirin 325 mg daily d. apply oxygen via nasal cannula e. avoid opirate-type analgesics

B, D, E hydroxyurea can reduce the number of sickling and pain episodes by stimulating fetal hemoglobin production. providing oxygen via nasal cannula provides additional oxygen, which decreases red blood cell sickling and improves tissue oxygenation. intravenous hydration will decrease the clumping of sickled cells and decrease obstruction of blood flow. strict isolation is not needed for clients in sickle cell crisis. aspirin is not helpful because the obstruction of blood flow is caused by obstruction of blood flow by sickled cells is very painful, and opiate analgesics are frequently needed for pain management.

which finding would the nurse expect when assessing a client who is in an early stage of multiple sclerosis? select all that apply. a. headache b. nystagmus c. skin infection d. scanning speech e. intention tremors

B, D, E involuntary, rhythmic movements of the eyes (nystagmus) and other visual disturbances, such as diplopia and blurred vision, are common initial symptoms of optic nerve lesions. some common initial signs of multiple sclerosis are scanning speech, intention tremors and nystagmus. these adaptations are associated with disseminated demyelination of nerve fivers of the brain and spinal cord. although this is a neuromuscular disorder, headaches are not a common symptom. pressure ulcers may occur late, not early, in the progression of the illness because of immobility, and these pressure ulcers may become infected.

A patient receiving sumatriptan for migraine headaches is experiencing adverse effects after taking the drug. Which adverse effect is of greatest concern to the nurse?

Triptan drugs are contraindicated in patients with coronary artery disease because they can cause arterial narrowing. Patients taking triptan drugs should report angina or chest discomfort to prevent cardiac injury associated with myocardial ischemia. Skin flushing, tingling feelings, and a warm sensation are common adverse effects with triptan medications and are not indications to avoid using this group of drugs.

Which statement by an adolescent about sickle cell anemia would cause the nurse to conclude that the teaching has been understood? a. "I'll start to have symptoms when I drink less fluid." b. "I'll start to have symptoms when I have fewer platelets." c. "I'll start to have symptoms when I decrease the iron in my diet." d. "I'll start to have symptoms when I have fewer white blood cells."

a. "I'll start to have symptoms when I drink less fluid." dehydration precipitates sickling of red blood cells and is a major causative factor for painful episodes associated with sickle cell anemia. an inadequate number of platelets (thombocytes) is unrelated to painful episodes associated with sickle cell anemia. iron intake is unrelated to the sickling phenomenon. an inadequate number of white blood cells is unrelated to painful episodes associated with sickle cell anemia.

A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate? a. "MS symptoms may be worse after the pregnancy." b. "Women with MS frequently have premature labor." c. "MS is associated with an increased risk for congenital defects." d. "Symptoms of MS are likely to become worse during pregnancy."

a. "MS symptoms may be worse after the pregnancy." During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Onset of labor is not affected by MS.

when both parents have sickle cell trait, what is the chance that a child will gave sickle cell disease? a. 25% b. 50% c. 75% d. 100%

a. 25% sickle cell is an autosomal recessive genetic disorder. if both individuals have sickle cell traits, there is a 25% chance they will produce a child with the disease. children will have a 50% chance of having sickle cell trait. a 75% chance of having offspring sickle cell trait or disease is not mathematically possible. a child born of parents who both have sickle cell disease will have 100% chance of having the disease.

Which action will the nurse include in the plan of care for a patient who has thalassemia major? a. Administer chelation therapy as needed. b. Teach the patient to use iron supplements. c. Avoid the use of intramuscular injections. d. Notify health care provider of hemoglobin 11 g/dL.

a. Administer chelation therapy as needed. The frequent transfusions used to treat thalassemia major lead to iron toxicity in patients unless iron chelation therapy is consistently used. Iron supplementation is avoided in patients with thalassemia. There is no need to avoid intramuscular injections. The goal for patients with thalassemia major is to maintain a hemoglobin of 10 g/dL or greater.

which information will the nurse provide to minimize the risk for complications of pancytopenia as a result of chemotherapy? a. Avoid traumatic injury and exposure to infection. b. perform frequent mouth care with a firm toothbrush c. Increase oral fluid intake to at least 3 L/day. d. Report unusual muscle cramps or tingling sensations in the extremities.

a. Avoid traumatic injury and exposure to infection. reduced platelets increase the likelihood of uncontrolled bleeding; reduced lymphocytes increase susceptibility to infection. aggressive oral hygiene can precipitate bleeding from the gums. although fluids may be increased to flush out the toxic by-products of chemotherapy, this has no effect on pancytopenia. muscle cramps or tingling sensations in the extremities are adaptations to hypocalcemia; hypocalcemia is unrelated to pancytopenia.

A client develops iron-deficiency anemia. Which of the client's laboratory test results should the nurse expect to be decreased? a. Ferritin level b. Platelet count c. White blood cell count d. Total iron-binding capacity

a. Ferritin level Ferritin, a form of stored iron, is reduced with iron-deficiency anemia. Platelets will be within the expected range or increased with iron-deficiency anemia. Red, not white, blood cells are decreased with iron-deficiency anemia. Total iron-binding capacity will be increased with iron-deficiency anemia.)

A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure? a. Focal b. Atonic c. Absence d. Myoclonic

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

A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for 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.

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

Which action will the nurse include in the plan of care for a patient admitted with multiple myeloma? a. Monitor fluid intake and output. b. Administer calcium supplements. c. Assess lymph nodes for enlargement. d. Limit weight bearing and ambulation.

a. Monitor fluid intake and output. A high fluid intake and urine output helps prevent the complications of kidney stones caused by hypercalcemia and renal failure caused by deposition of Bence-Jones protein in the renal tubules. Weight bearing and ambulation are encouraged to help bone retain calcium. Lymph nodes are not enlarged with multiple myeloma. Calcium supplements will further increase the patient's calcium level and are not used.

Which menu choice indicates that the patient understands the nurse's recommendations about dietary choices for iron-deficiency anemia? a. Omelet and whole wheat toast b. Cantaloupe and cottage cheese c. Strawberry and banana fruit plate d. Cornmeal muffin and orange juice

a. Omelet and whole wheat toast Eggs and whole grain breads are high in iron. The other choices are appropriate for other nutritional deficiencies but are not the best choice for a patient with iron-deficiency anemia.

A patient with immune thrombocytopenic purpura (ITP) has an order for a platelet transfusion. Which information indicates that the nurse should consult with the health care provider before obtaining and administering platelets? a. Platelet count is 42,000/uL. b. Blood pressure is 94/56 mm Hg. c. Petechiae are present on the chest. d. Blood is oozing from the venipuncture site.

a. Platelet count is 42,000/uL. platelet transfusions are not usually indicated until the platelet count is below 10,000 to 20,000/uL unless the patient is actively bleeding. Therefore, the nurse should clarify the order with the health care provider before giving the transfusion. The other data all indicate that bleeding caused by ITP may be occurring and that the platelet transfusion is appropriate.

Ten minutes after the initiation of a blood transfusion, a client reports chills and flank pain. Which nursing action would be performed first? a. Stop the transfusion. b. Obtain the vital signs. c. Notify the health care provider. d. Maintain the flow with normal saline.

a. Stop the transfusion. This is a sign of an acute hemolytic transfusion reaction, indicating that the recipient's blood is incompatible with the transfused blood; pain is caused by hemolysis, agglutination, and capillary plugging in the kidneys. Obtaining the vital signs is important but must not precede stopping the transfusion because more incompatible blood will be infused, increasing the severity of the transfusion reaction. After the infusion is stopped, the provider should be notified and normal saline should be infused to keep the line patent.

Which nursing intervention is appropriate for a patient with non Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy? a. Test all stools for occult blood. b. Encourage fluids to 3000 mL/day. c. Provide oral hygiene every 2 hours. d. Check the temperature every 4 hours.

a. Test all stools for occult blood. Because the patient is at risk for spontaneous bleeding, the nurse should check stools for occult blood. A low platelet count does not require an increased fluid intake. Oral hygiene is important, but it is not necessary to provide oral care every 2 hours. The low platelet count does not increase risk for infection, so frequent temperature monitoring is not indicated.

Which instruction about phenytoin will the nurse provide during discharge teaching to a client with epilepsy who is prescribed phenytoin for seizure control? a. antiseizure medications will probably be continued for life b. phenytoin prevents any further occurrence of seizures c. this medication needs to be taken during periods of emotional stress d. your antiseizure medication usually can be stopped after a year's absence of seizures

a. antiseizure medications will probably be continued for life seizure disorders usually are associated with marked changes in the electrical activity of the cerebral cortex, requiring prolonged or lifelong therapy. seizures may occur despite medication therapy; the dosage may need to be adjusted. a therapeutic blood level must be maintained through consistent administration of the medication irrespective of emotional stress. absence of seizures will probably result from medication effectiveness rather than from correction of the pathophysiological condition.

The nurse observes a patient ambulating in the hospital hall when the patient's arms and legs suddenly jerk and the patient falls to the floor. The nurse will 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.

a. 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 are also appropriate actions, but the initial action should be assessment for injury.

The nurse advises a patient with myasthenia gravis (MG) to a. perform physically demanding activities early in the day. b. anticipate the need for weekly plasmapheresis treatments. c. do frequent weight-bearing exercise to prevent muscle atrophy. d. protect the extremities from injury due to poor sensory perception.

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

A patient who has acute myelogenous leukemia (AML) asks the nurse whether the planned chemotherapy will be worth undergoing. Which response by the nurse is appropriate? a. "If you do not want to have chemotherapy, other treatment options include stem cell transplantation." b. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." c. "The decision about treatment is one that you and the doctor need to make rather than asking what I would do." d. "You don't need to make a decision about treatment right now because leukemias in adults tend to progress slowly."

b. "The side effects of chemotherapy are difficult, but AML often goes into remission with chemotherapy." This response uses therapeutic communication by addressing the patient's question and giving accurate information. The other responses either give inaccurate information or fail to address the patient's question, which will discourage the patient from asking the nurse for information

which instruction will the nurse give a client with migraine headaches who is starting triptan medication therapy? a. "check your pulse before and after administration" b. "report any chest discomfort to the health care provider" c. "wait for 1 hour after symptom onset to administer the medication" d. "stop taking the medication if you experience warm, flushing sensations"

b. "report any chest discomfort to the health care provider" clients need to be instructed to report chest discomfort to the health care provider immediately. clients taking triptan medications who experience chest discomfort must be investigated for myocardial ischemia. clients on beta-blocker therapy for migraines, not triptan therapy, will be instructed to monitor pulse. triptan medications are taken as soon as symptoms appear. warm, flushing sensations are a common experience in clients taking triptan medication; the side effect generally subsides with continued use and does not indicate a need to stop the medication.

Several patients call the outpatient clinic and ask to make an appointment as soon as possible. Which patient should the nurse schedule to be seen first? a. A 44-yr-old with sickle cell anemia who says his eyes always look yellow b. A 23-yr-old with no previous health problems who has a nontender axillary lump c. A 50-yr-old with early-stage chronic lymphocytic leukemia who reports chronic fatigue d. A 19-yr-old with hemophilia who wants to learn to self-administer factor VII

b. A 23-yr-old with no previous health problems who has a nontender axillary lump The patient's age and presence of a nontender axillary lump suggest possible lymphoma, which needs rapid diagnosis and treatment. The other patients have questions about treatment or symptoms that are consistent with their diagnosis but do not need to be seen urgently.

A postoperative patient receiving a transfusion of packed red blood cells develops chills, fever, headache, and anxiety 35 minutes after the transfusion is started. After stopping the transfusion, what action should the nurse take? a. Send a urine specimen to the laboratory. b. Administer PRN acetaminophen (Tylenol). c. Draw blood for a new type and crossmatch. d. Give the prescribed PRN diphenhydramine

b. Administer PRN acetaminophen (Tylenol). The patient's clinical manifestations are consistent with a febrile, nonhemolytic transfusion reaction. The transfusion should be stopped, and antipyretics administered for the fever as ordered. A urine specimen is needed if an acute hemolytic reaction is suspected. Diphenhydramine is used for allergic reactions. This type of reaction does not indicate incorrect crossmatching.

Which intervention will be included in the nursing care plan for a patient with immune thrombocytopenic purpura? a. Assign the patient to a private room. b. Avoid intramuscular (IM) injections. c. Use rinses rather than a soft toothbrush for oral care. d. Restrict activity to passive and active range of motion.

b. Avoid intramuscular (IM) injections. IM or subcutaneous injections should be avoided because of the risk for bleeding. A soft toothbrush can be used for oral care. There is no need to restrict activity or place the patient in a private room.

A young adult who has von Willebrand disease is admitted to the hospital for minor knee surgery. Which laboratory value should the nurse monitor? a. Platelet count b. Bleeding time c. Thrombin time d. Prothrombin time

b. Bleeding time The bleeding time is affected by von Willebrand disease. Platelet count, prothrombin time, and thrombin time are normal in von Willebrand disease

A routine complete blood count for an active older man indicates possible myelodysplastic syndrome. What should the nurse plan to explain to the patient? a. Blood transfusion b. Bone marrow biopsy c. Filgrastim administration d. Erythropoietin administration

b. Bone marrow biopsy Bone marrow biopsy is needed to make the diagnosis and determine the specific type of myelodysplastic syndrome. The other treatments may be necessary later if there is progression of the myelodysplastic syndrome, but the initial action for this asymptomatic patient will be a bone marrow biopsy.

Which action will the admitting nurse include in the care plan for a patient who has neutropenia? a. Avoid intramuscular injections. b. Check temperature every 4 hours. c. Place a "No Visitors" sign on the door. d. Omit fruits and vegetables from the diet.

b. Check temperature every 4 hours. The earliest sign of infection in a neutropenic patient is an elevation in temperature. While unpeeled fresh fruits and vegetables should be avoided, fruits and vegetables that are peeled or cooked are acceptable. Injections may be required for administration of medications such as filgrastim (Neupogen). The number of visitors may be limited and visitors with communicable diseases should be avoided, but a "no visitors" policy is not needed.

Which nursing intervention is important when providing care for a patient with sickle cell crisis? a. Limiting the patient's intake of oral and IV fluids b. Evaluating the effectiveness of opioid analgesics c. Encouraging the patient to ambulate as much as tolerated d. Teaching the patient about high-protein, high-calorie foods

b. Evaluating the effectiveness of opioid analgesics Pain is the most common clinical manifestation of a crisis and usually requires large doses of continuous opioids for control. Fluid intake should be increased to reduce blood viscosity and improve perfusion. Rest is usually ordered to decrease metabolic requirements. Patients are instructed about the need for dietary folic acid, but high-protein, high-calorie diets are not emphasized

A patient who is receiving methotrexate for severe rheumatoid arthritis develops a megaloblastic anemia. Which nutrient supplement should the nurse plan to explain to the patient? a. Iron b. Folic acid c. Cobalamin (vitamin B12) d. Ascorbic acid (vitamin C)

b. Folic acid Methotrexate use can lead to folic acid deficiency. Supplementation with oral folic acid supplements is the usual treatment. The other nutrients would not correct folic acid deficiency, although they would be used to treat other types of anemia.

Which potential complication should the nurse identify as a high risk for a patient admitted to the hospital with idiopathic aplastic anemia? a. Seizures b. Infection c. Neurogenic shock d. Pulmonary edema

b. Infection Because the patient with aplastic anemia has pancytopenia, the patient is at risk for infection and bleeding. There is no increased risk for seizures, neurogenic shock, or pulmonary edema

After a thymectomy, a patient with myasthenia gravis receives the usual dose of pyridostigmine (Mestinon). An hour later, the patient complains of 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).

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

When a patient with splenomegaly is scheduled for splenectomy, which action will the nurse include in the preoperative plan of care? a. Recommend ibuprofen for left upper quadrant pain. b. Schedule immunization with the pneumococcal vaccine. c. Avoid the use of acetaminophen (Tylenol) for 2 weeks prior to surgery. d. Discourage deep breathing and coughing to reduce risk for splenic rupture.

b. Schedule immunization with the pneumococcal vaccine. Asplenic patients are at high risk for infection with pneumococcal infections and immunization reduces this risk. There is no need to avoid acetaminophen use before surgery, but nonsteroidal antiinflammatory drugs (NSAIDs) may increase bleeding risk and should be avoided. The enlarged spleen may decrease respiratory depth, and the patient should be encouraged to take deep breaths.

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

b. Suggest that the patient rock from side to side to initiate leg movement. Rocking the body from side to side stimulates balance and improves mobility. The patient will be encouraged to continue exercising because this will maintain functional abilities. Maintaining a wide base of support will help with balance. The patient should lift the feet and avoid a shuffling gait.

Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder? a. Encourage a 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.

b. 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.

A patient who has a history of a transfusion-related acute lung injury (TRALI) is to receive a transfusion of packed red blood cells (PRBCs). Which action by the nurse will decrease the risk for TRALI for this patient? a. Infuse PRBCs slowly over 4 hours. b. Transfuse leukocyte-reduced PRBCs. c. Administer the prescribed diuretic before the transfusion. d. Give the PRN dose of antihistamine before the transfusion.

b. Transfuse leukocyte-reduced PRBCs. TRALI is caused by a reaction between the donor and the patient leukocytes that causes pulmonary inflammation and capillary leaking. The other actions may help prevent respiratory problems caused by circulatory overload or by allergic reactions, but they will not prevent TRALI.

A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse consider to be a high priority for the client? a. Oral hydroxyurea b. Vitamin B 12 injections c. Oral iron supplements d. Erythropoietin injections

b. Vitamin B 12 injections A shiny tongue, paresthesias of the limbs, ataxia, and cobalamin of 125 pg/mL (normal: 200- 835 pg/mL) are the manifestations of pernicious anemia. The client has pernicious anemia due to a vitamin B 12 deficiency and should be given vitamin B 12 injections. Vitamin B 12 cannot be given orally to a client with pernicious anemia because the client does not produce the intrinsic factors needed to absorb Vitamin B 12. Hydroxyurea is administered orally to clients with hemochromatosis. Oral iron supplements are given to clients with iron deficiency anemia. Erythropoietin injections are given to clients who have low red blood cells, hemoglobin, and hematocrit.

which information would the nurse include in the teaching plan for a client diagnosed with epilepsy? a. the client will take anticonvulsant medications for life b. individuals taking phenytoin must floss their teeth regularly c. a diagnosis of epilepsy prevents individuals from ever obtaining a driver's license d. loss of consciousness during a seizure requires emergency evaluation

b. individuals taking phenytoin must floss their teeth regularly gingival hyperplasia is a common side effect of phenytoin. clients may decrease or delay development of gingival hyperplasia by regular brushing and flossing of their teeth. although lifelong treatment with antiseizure medication is often required, some people are able to wean from antiseizure medication after they have been seizure free for a period of several years (generally 3 to 5) and have a normal electroencephalogram and neurological examination. driving laws for people with epilepsy vary from state to state. for example, some states require a seizure-free period of up to a year before reinstating or issuing a driver's license. The person who has experienced a single seizure may not need to go to the hospital, unless the event is a first-time seizure, the seizure is prolonged or the seizure results in bodily harm.

When obtaining a health history and physical assessment for a 36-yr-old female patient with possible multiple sclerosis (MS), the nurse should a. assess for the presence of chest pain. b. inquire about urinary tract problems. c. inspect the skin for rashes or discoloration. d. ask the patient about any increase in libido.

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

The nurse expects the assessment of a patient who is experiencing a cluster headache to include a. nuchal rigidity. b. unilateral ptosis. c. projectile vomiting. d. throbbing, bilateral facial pain.

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

Which patient statement to the nurse indicates that the patient understands self-care for pernicious anemia? a. "I need to start eating more red meat and liver." b. "I will stop having a glass of wine with dinner." c. "I could choose nasal spray rather than injections of vitamin B12." d. "I will need to take a proton pump inhibitor such as omeprazole (Prilosec)."

c. "I could choose nasal spray rather than injections of vitamin B12." Because pernicious anemia prevents the absorption of vitamin B12, this patient requires injections or intranasal administration of cobalamin. Alcohol use does not cause cobalamin deficiency. Proton pump inhibitors decrease the absorption of vitamin B12. Eating more foods rich in vitamin B12 is not helpful because the lack of intrinsic factor prevents absorption of the vitamin.

A registered nurse teaches a nursing student about cluster headaches. Which statement made by the nursing student indicates a need for further teaching? a. "Each episode of a cluster headache may last up to 3 hours." b. "Pupillary constriction occurs during the period of cluster headaches." c. "Pulsating pain is the characteristic type of pain that occurs in cluster headaches." d. "Cluster headaches occur for weeks to months followed by a period of remission."

c. "Pulsating pain is the characteristic type of pain that occurs in cluster headaches." sharp stabbing pain is the characteristic type of pain that occurs in cluster headaches. each episode of a cluster headache may last from a few minutes to 3 hours. constriction of the pupil, swelling around the eye, and facial flushing occur during the period of cluster headaches. a period of remission after a few weeks or months of headaches is characteristic of cluster headaches.

Which prescribed intervention will the nurse implement first for a patient in the emergency department 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.

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

Which immunomodulatory is beneficial for the treatment of clients with multiple sclerosis? a. Interleukin 2 b. Interleukin 11 c. Beta interferon d. Alpha interferon

c. Beta interferon beta interferon is an immunomodulator administered in the treatment of multiple sclerosis. IL-2 treats metastatic renal cell carcinoma and metastatic melanoma. interleukin 11 (IL-11) prevents development of thrombocytopenia after chemotherapy. alpha interferon treats hairy cell leukemia, chronic myelogenous leukemia, and malignant melanoma.

Which finding about a patient with polycythemia vera is most important for the nurse to report to the health care provider? a. Hematocrit 55% b. Presence of plethora c. Calf swelling and pain d. Platelet count 450,000/uL

c. Calf swelling and pain The calf swelling and pain suggest that the patient may have developed a deep vein thrombosis, which will require diagnosis and treatment to avoid complications such as pulmonary embolus. The other findings will also be reported to the health care provider but are expected in a patient with this diagnosis..

Which action would the nurse take next after the nurse immediately stops the infusion of a client demonstrating signs and symptoms of a transfusion reaction? a. Obtain blood pressure in both arms b. Send a urine specimen to the laboratory c. Hang a bag of normal saline with new tubing d. Monitor the intake and output every 15 minutes

c. Hang a bag of normal saline with new tubing The tubing must be replaced to avoid infusing the blood left in the original tubing; the normal saline infusion will maintain an open line for any further intravenous (IV) treatment. All vital signs should be taken eventually; blood pressure may be taken on either arm, not necessarily both. A urine sample is collected after the blood transfusion is stopped, the tubing replaced, and a bag of normal saline hung. The specimen will be analyzed to determine kidney function. Although the intake, and especially the output, should be monitored to assess kidney function, this is not the priority.

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

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

Which 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 has minor elevations in the liver function tests. d. Patient's most recent blood pressure is 156/92 mm Hg.

c. Patient has minor elevations in the liver function tests. 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.

Which assessment is most important for the nurse to make regarding a patient with myasthenia gravis? a. Pupil size b. Grip strength c. Respiratory effort d. Level of consciousness

c. 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.

which prescribed treatment would the nurse question when a client who has sickle cell anemia has been admitted with acute chest syndrome? a. oxygen administration b. daily folic acid tablet c. daily iron supplement d. morphine sulfate prn

c. daily iron supplement the nurse would question the use of iron supplements in sickle cell anemia because sickle cell disease is not caused by iron deficiency. in addition, many clients with sickle cell anemia receive blood transfusions and iron toxicity can develop secondary to frequent transfusions. oxygen administration would be appropriate for a client with a pulmonary complication such as acute chest syndrome. folic acid supplements are recommended for clients with sickle cell disease because folic acid is needed in the production of new red blood cells to replace cells lost to hemolysis. morphine sulfate is frequently prescribed to treat ischemic pain caused by sickled cells.

Which information does the nurse include in the teaching plan for the client who is prescribed sumatriptan for migraine headache? a. it should be administered when headache is at its peak b. it should be administered by deep Intramuscular injection c. is contraindicated in people with coronary artery disease d. injectable sumatriptan may be administered every 6 hours as needed

c. is contraindicated in people with coronary artery disease in addition to promoting therapeutic cerebral vasoconstriction, sumatriptan promotes undesirable coronary artery vasoconstriction. coronary vasoconstriction may cause harm to the client with coronary artery disease. for maximum effectiveness, sumatriptan should be administered at the onset of migraine headache. sumatriptan may be given orally, subcutaneously, or as a nasal spray. the maximum adult dose of sumatriptan may be given orally, subcuntenously, or as a nasal spray. the maximum adult dose of sumatriptan is two 6-mg doses in a 24-hour period for a total of 12 milligrams. the two doses must be separated by at least an hour. the second dose should not be administered unless some response was observed with the first dose.

A 40-yr-old patient is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and adult children about this disorder, the nurse will provide information about the a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms. b. prophylactic antibiotics to decrease the risk for aspiration pneumonia. c. option of genetic testing for the patient's children to determine their own HD risks. d. lifestyle changes of improved nutrition and exercise that delay disease progression.

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

Which statement by a patient indicates good understanding of the nurse's teaching about preventing sickle cell crisis? a. "Home oxygen therapy is frequently used to decrease sickling." b. "There are no effective medications that can help prevent sickling." c. "Routine continuous dosage opioids are prescribed to prevent a crisis." d. "Risk for a crisis is decreased by having an annual influenza vaccination."

d. "Risk for a crisis is decreased by having an annual influenza vaccination." Because infection is the most common cause of a sickle cell crisis, influenza, Haemophilus influenzae, pneumococcal pneumonia, and hepatitis immunizations should be administered. Although continuous dose opioids and oxygen may be administered during a crisis, patients do not receive these therapies to prevent crisis. Hydroxyurea (Hydrea) is a medication used to decrease the number of sickle cell crises

Which laboratory test will the nurse use to determine whether filgrastim (Neupogen) is effective for a patient with acute lymphocytic leukemia who is receiving chemotherapy? a. Platelet count b. Reticulocyte count c. Total lymphocyte count d. Absolute neutrophil count

d. Absolute neutrophil count Filgrastim increases the neutrophil count and function in neutropenic patients. Although total lymphocyte, platelet, and reticulocyte counts are also important to monitor in this patient, the absolute neutrophil count is used to evaluate the effects of filgrastim.

Which laboratory result will the nurse expect to show a decreased value if a patient develops heparin-induced thrombocytopenia (HIT)? a. Prothrombin time b. Erythrocyte count c. Fibrinogen degradation products d. Activated partial thromboplastin time

d. Activated partial thromboplastin time Platelet aggregation in HIT causes neutralization of heparin, so the activated partial thromboplastin time will be shorter, and more heparin will be needed to maintain therapeutic levels. The other data will not be affected by HIT.

An adult male with chronic anemia is experiencing increased fatigue and occasional palpitations at rest. Which laboratory data would the nurse identify as consistent with these symptoms? a. RBC count of 4,500,000/uL b. Hematocrit (Hct) value of 38% c. Normal red blood cell (RBC) indices d. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L)

d. Hemoglobin (Hgb) of 8.6 g/dL (86 g/L) The patient's symptoms indicate moderate anemia, which is consistent with a Hgb of 6 to 10 g/dL. The other values are all within the range of normal.

Which nursing diagnosis is of highest priority for a patient with Parkinson's disease who is unable to move the facial muscles? a. Activity intolerance b. Self-care deficit: toileting c. Ineffective self-health management d. Imbalanced nutrition: less than body requirements

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

A patient who has non-Hodgkin's lymphoma is receiving combination treatment with rituximab (Rituxan) and chemotherapy. Which patient assessment finding requires the most rapid action by the nurse? a. Anorexia b. Vomiting c. Oral ulcers d. Lip swelling

d. Lip swelling Lip swelling in angioedema may indicate a hypersensitivity reaction to the rituximab. The nurse should stop the infusion and further assess for anaphylaxis. The other findings may occur with chemotherapy but are not immediately life threatening.

What action is expected by the nurse caring for a patient who has an acute exacerbation of polycythemia vera? a. Place the patient on bed rest. b. Administer iron supplements. c. Avoid use of aspirin products. d. Monitor fluid intake and output.

d. Monitor fluid intake and output. Monitoring hydration status is important during an acute exacerbation because the patient is at risk for fluid overload or underhydration. Aspirin therapy is used to decrease risk for thrombosis. The patient should be encouraged to ambulate to prevent deep vein thrombosis. Iron is contraindicated in patients with polycythemia vera.

Following successful treatment of Hodgkin's lymphoma for a 55-yr-old woman, which topic will the nurse include in patient teaching? a. Potential impact of chemotherapy treatment on fertility b. Application of soothing lotions to treat residual pruritus c. Use of maintenance chemotherapy to maintain remission d. Need for follow-up appointments to screen for malignancy

d. Need for follow-up appointments to screen for malignancy The chemotherapy used in treating Hodgkin's lymphoma results in a high incidence of secondary malignancies; follow-up screening is needed. Chemotherapy will not impact the fertility of a 55-yr-old woman. Maintenance chemotherapy is not used for Hodgkin's lymphoma. Pruritus is a clinical manifestation of lymphoma but should not be a concern after treatment.

Which information is most important for the nurse to monitor when evaluating the effectiveness of deferoxamine (Desferal) for a patient with hemochromatosis? a. Skin color b. Hematocrit c. Liver function d. Serum iron level

d. Serum iron level Because iron chelating agents are used to lower serum iron levels, the most useful information will be the patient's iron level. The other parameters will also be monitored but are not the most important to monitor when determining the effectiveness of deferoxamine

a client asks the nurse what causes the sudden loss of vision common in persons with multiple sclerosis. which factor would the nurse include in the explanation? a. virus-induced iritis b. intracranial pressure c. closed-angle glaucoma d. optic nerve inflammation

d. optic nerve inflammation optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). this effect may resolve during periods of remission. at present, there is no evidence of viral infection of the eyes in multiple sclerosis. tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. closed-angle glaucoma is unrelated to multiple sclerosis.

which symptom would the nurse expect to decrease in response to corticosteroid therapy prescribed for a client with multiple sclerosis? a. emotional lability b. muscular contractions c. pain in the extremities d. visual impairment

d. visual impairment corticosteroids decrease the inflammatory process around the optic nerve, thus improving vision; visual impairment is the most common physiological manifestation of multiple sclerosis. steroids are associated with increased emotional lability. steroids are not effective in easing muscle contractions. pain in the extremities is not common unless spasms are present; steroids do not relieve spasms.