Unit 2

Initially, which response would the nurse use when a patient who developed seizures after a head injury reports feeling as though he or she has lost control over his or her life?

"tell me about what you would like to do and how the seizures affect you" asking the pt what they would like to do and how the seizures affect them is correct because it addresses their concerns

Which patient conditions increase the risk of developing heart failure? Select all that apply.

- anemia - thyrotoxicosis - pagets disease - bacterial endocarditis

A patient is suspected of having heart failure. Which diagnostic tests are commonly used to make this diagnosis?

- chest x-ray - echocardiogram - electrocardiogram (ECG)

Which information would the nurse include when teaching a patient with multiple sclerosis about the advantages of exercise during remission?

- decreases spasticity - increases coordination - retrains unaffected muscles to substitute for impaired ones Encourage patients with multiple sclerosis in remission to exercise. Regular exercise can help to decrease spasticity, increase coordination, and retrain unaffected muscles to substitute for the impaired ones. The exercise does not help to regain bladder control or delay the demyelination process

The nurse is caring for a patient who develops atrial fibrillation. Which treatments may be included the patient's treatment plan?

- electrical cardioversion - anticoagulation therapy - radiofrequency catheter ablation

A patient with chest pain experiences a heart rate of 200 beats/min and BP of 80/50 mm Hg. The electrocardiogram shows absent P waves. Which IV medication would the nurse expect will be prescribed?

Adenosine

Lou Gehrig's disease (ALS)

Lou Gehrig's disease is a rare progressive neurologic disorder involving degeneration of motor neurons in the spinal cord and brain; characteristics include limb weakness, dysarthria, and dysphagia.

Which symptom indicates that a patient may have a pulmonary embolism?

Tachypnea Tachypnea indicates a potential pulmonary embolism. Agitation, rather than lethargy, is a symptom of pulmonary embolism. A patient with a pulmonary embolism would be more likely to present with tachycardia and hypotension rather than bradycardia and hypertension.

Which medication is used to manage a complication of atrial fibrillation?

Warfarin A complication of atrial fibrillation is clot formation in the atria due to blood pooling. Warfarin is an anticoagulant to prevent this complication. Digoxin, diltiazem, and metoprolol are medications used to treat the actual abnormality/diagnosis of atrial fibrillation.

Which condition related to heart failure causes fatigue?

decreased oxygenation of the tissues

Which symptom is present in right-sided heart failure but not in left-sided heart failure?

pedal edema Right-sided heart failure is manifested as bilateral pedal and sacral edema in the patient. Fatigue, anxiety, and depression are symptoms of both right-sided and left-sided heart failure.

A patient's electrocardiogram (ECG) tracing shows occasional wide and distorted QRS complexes. Which rhythm does this finding indicate?

premature ventricular contractions

A patient with chronic heart failure is being discharged from the hospital. Which instructions would the nurse include in the patient's teaching plan?

report a weight gain of 3 lb in two days

Which statement is accurate regarding the role of the autonomic nervous system in impulse formation?

stimulation of the vagus nerve causes a decreased rate of firing of the SA node

Which intervention would the nurse implement as a priority when providing care for a patient with a diagnosis of multiple sclerosis (MS)?

vigilant infection control and adherence to standards precautions Infection control is a priority in the care of patients with MS because infection is the most common cause of an exacerbation of the disease. Decreases in cognitive function are less likely, and MS typically does not result in malnutrition, hypotension, or fluid volume excess or deficit.

The nurse provides discharge teaching to a patient who received an implantable cardioverter-defibrillator (ICD) in the left side of the chest. Which statement made by the patient indicates the need for further teaching?

"I cannot fly because the security devices at the airport will damage the ICD" The patient statement that flying will damage the ICD indicates misunderstanding about flying. The patient should be taught that the Transportation Security Administration (TSA) should be informed about the ICD because it may set off the metal detector, and if a hand-held screening wand is used it should not be placed directly over the ICD.

The nurse is teaching a student nurse about pulmonary embolism. Which response by the student indicates to the nurse teaching was effective?

"a clot in the iliac vein may lead to a potentially lethal pulmonary emboli" Pulmonary embolism is a blockage of the pulmonary artery by thrombus, air or fat embolus, or tumor cells. About 90% of pulmonary emboli results from deep vein thrombosis in the deep veins of the legs, such as the iliac vein

A patient undergoing treatment for dysrhythmia is provided with a Holter monitor. Which information would the nurse include in the patient teaching about the test?

- a patient should record activities and any symptoms in a diary - a monitor records the ECG when the patient is ambulatory - new technology using smart phone apps can obtain and save ECG recordings - the monitor records the ECG when the patient performs daily activities

The nurse is caring for a patient who is experiencing symptomatic sinus bradycardia. Which drugs are used to treat this rhythm?

- atropine - dopamine - epinephrine Sinus bradycardia is a condition in which the sinoatrial node elicits a heartbeat at a rate of less than 80 beats/min, sinus bradycardia is associated with hypotension, weakness, dizziness, and shortness of breath. It can be treated by the administration of atropine, an anticholinergic drug. Sympathomimetic drugs like dopamine and epinephrine are administered if atropine is ineffective

Which clinical manifestations would the nurse expect to identify when assessing a patient with a spastic bladder secondary to multiple sclerosis?

- bladder contractions are unchecked - the bladder has a small capacity for urine - the patient experiences incontinence and dribbling A patient with spastic bladder may experience unchecked bladder contraction, and the bladder may have a small capacity for urine. Both factors may result in urine urgency and frequency and cause incontinence and dribbling. Sensation of an urge to void is present in patients with spastic bladder but absent in patients with flaccid bladder, who may have urinary retention due to a large bladder capacity for urine.

Which information would the nurse provide the concerned parents of a child recently diagnosed with typical absence seizures?

- brief staring spells are a characteristic of the seizure - flashing lights usually precipitate this type of seizure activity - the occurrence of seizures usually subsides during adolescence The typical absence seizure usually occurs in childhood only, and the occurrences subside in adolescence. Brief staring spells that last for only a few seconds are a characteristic of the seizure. Flashing lights tend to precipitate a seizure. The child may not have loss of postural tone and may not experience confusion after a seizure.

For the patient with Parkinson's disease, which dietary adjustments would the nurse include in the plan of care to prevent malnutrition and constipation?

- cut food into bite-size pieces - serve hot foods on a warmed plate - include whole grains and fruits in the diet Patients with Parkinson's disease are predisposed to malnutrition and constipation, owing to inadequate food intake caused by difficulty in chewing and swallowing. To promote adequate nutrition, the nurse should include whole grains and fruits in the diet, which will prevent constipation. Cut food into bite-size pieces so chewing and swallowing are easy. Serving hot foods on a warmed plate makes the food more appealing. Limit food items high in protein because they can interfere with the absorption of carbidopa-levodopa, the most common drug used in the treatment of Parkinson's disease. Six small meals, rather than three large meals, would be less exhausting for the patients.

When performing a physical examination of a patient with Parkinson's disease, which associated clinical manifestations would the nurse likely identify?

- drooling of saliva - decreased arm swing - shuffling, propulsive gait The patient may manifest drooling of saliva, shuffling, propulsive gait, and decreased arm swing. These symptoms are due to the combination of tremors, rigidity of muscles, and bradykinesia.

A patient with a history of deep vein thrombosis is recovering in the postanesthesia care unit (PACU) after surgery. Which symptoms would the nurse assess if this patient develops a pulmonary embolism (PE)?

- dyspnea - tachypnea - tachycardia PE can be recognized by the presence of tachycardia, tachypnea, and dyspnea, especially if the patient is already receiving oxygen therapy. PE may occur in a postoperative patient who already has a history of deep vein thrombosis and is an older adult. Other symptoms of PE may include agitation, chest pain, hypotension, hemoptysis, dysrhythmias, and heart failure.

Which information would the nurse provide the caregiver of a patient with acute seizures regarding actions to implement if another seizure occurs at home?

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

The nurse is caring for a patient with right-sided heart failure. Which assessment findings would the nurse expect?

- edema - ascites - anasarca Edema, ascites, and anasarca are manifestations of right-sided heart failure caused by fluid retention. Crackles and wheezes are manifestations of left-sided heart failure because fluid moves from the pulmonary capillary bed into the pulmonary interstitium and alveoli.

The nurse presents education related to pulmonary embolism (PE) to a group of nursing students and includes which risk factors?

- immobility - pregnancy - pelvic surgery within the last three months - cigarette smoking Risk factors for PE include immobility or reduced mobility, surgery within the last three months (especially pelvic and lower extremity surgery), history of venous thromboembolism, cancer, obesity, oral contraceptives, hormone therapy, cigarette smoking, prolonged air travel, heart failure, pregnancy, and clotting disorders

When performing a physical assessment on a patient with amyotrophic lateral sclerosis (ALS), which clinical manifestations would the nurse identify? Select all that apply.

- limb weakness - difficulty swallowing - difficulty articulating words Amyotrophic lateral sclerosis is a rare, progressive neurologic disorder characterized by loss of motor neurons. Characteristics of the disease are limb weakness, difficulty in articulating words (dysarthria), and difficulty in swallowing (dysphagia). The symptoms are due to denervation of the muscles and lack of stimulation and use.

A patient is diagnosed with pulmonary embolism. Which interventions are appropriate to be included in the patient's plan of care?

- monitor the patients hemoglobin level - maintain an IV line for medications and fluid therapy - monitor for complications of anticoagulant therapy Pulmonary embolism requires prompt treatment. The nurse should monitor the patient's hemoglobin level and assess the patient for bleeding. An IV line should be maintained for medications and fluid therapy. Anticoagulants and fibrinolytics may have adverse effects, and the nurse should monitor the patient for side effects. The patient typically is placed in the semi-Fowler's position to assist in breathing. The patient should be encouraged to cough and perform deep-breathing exercises.

Which instruction would the nurse include in discharge teaching for a patient with an implantable cardioverter-defibrillator (ICD)?

- obtain an wear a medic alert ID device at all times - avoid large magnets and strong electromagnetic fields - avoid lifting the arm on ICD side above the shoulder until approved

When admitted with status epilepticus, which long-acting antiseizure medications would the nurse associate with the treatment of a patient's seizure disorder?

- phenytoin (Dilantin) - lamotrigine (Lamictal) - phenobarbital (Luminal) Phenytoin, lamotrigine, and phenobarbital are the drugs with a long half-life used in treating status epilepticus. Diazepam and lorazepam are the rapid-acting drugs used in the treatment of status epilepticus. They have a short half-life.

Which criterion would the nurse associate with the health care provider's diagnosis of Parkinson's disease (PD)?

- positive response to antiparkinsonian medications - presence of two of the three classic features: rigidity, bradykinesia, and tremor Presently, there is no specific test to diagnose PD. When the patient demonstrates two of the three classic signs: rigidity (increased resistance to passive motion as a cogwheel), bradykinesia (slowed and loss of automatic coordinated movement), and tremor (a tremor that is more severe at rest and pill-rolling hand tremor), the diagnosis occurs. Confirmation of the PD diagnosis is a positive response to medications used to treat the disease, such as carbidopa/levodopa. The cause of PD is decreased dopamine levels in the brain and inability to measure dopamine in the serum. Tumors of the thymus gland are associated with myasthenia gravis. MRI of patients with multiple sclerosis indicate areas of plaque development.

When admitting a female patient with a diagnosis of pulmonary embolism (PE), the nurse assesses for which risk factors?

- pregnancy - cancer - oral contraceptive use - hormone therapy Risk factors for PE include immobility or reduced mobility, surgery within the last three months (especially pelvic and lower extremity surgery), history of venous thromboembolism (VTE), cancer, obesity, oral contraceptives, hormone therapy, cigarette smoking, prolonged air travel, heart failure, pregnancy, and clotting disorders. Pneumonia is not a risk factor.

During an acute exacerbation of the patient's multiple sclerosis, which interventions would the nurse implement?

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

Which effects of nitroglycerin benefit a patient with acute decompensated heart failure (ADHF)? Select all that apply

- reduces preload - dilates the coronary arteries - increases myocardial oxygen supply Nitroglycerin is a medication that decreases preload, dilates the coronary arteries, and improves blood flow with oxygenation to the myocardium. Nitroglycerin has no dysrhythmic properties and does not prevent thromboembolism.

Which instructions would the nurse provide the patient who has a history of focal seizures, controlled with phenytoin (Dilantin), and mild gingival hyperplasia?

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

Which interventions would the nurse implement immediately for the patient experiencing generalized tonic-clonic seizures due to hypoxia?

- remove restrictive clothes - ensure the presence of a patent airway Hypoxia is a metabolic disturbance that can cause seizures. In this case, treat the underlying cause first to control the seizure. Manage hypoxia by ensuring a patent airway and removing tight clothes.

In which order would the nurse anticipate the various phases of a generalized tonic-clonic seizure?

- the patient loses consciousness - the patient fall to the ground - the body stiffens for 10 to 20 seconds - the extremities jerk for 30 to 40 seconds - the patient feels tired and sleepy

Which caregiver's actions, implemented during the patient's acute seizure episode, indicates understanding of the home care measures taught prior to discharge?

- turning the pt to their side - loosening the pts tight clothing - easing the pt to the floor, if seated The caregiver should turn the patient to his or her side to protect the patient from injury. Loosening any restrictive clothing of the patient will ensure a patent airway. Similarly, if seated, easing the patient to the floor will help to protect the patient from injuries. It is not necessary to send a patient immediately to the hospital after a seizure, unless the seizure is prolonged, or another seizure immediately follows. Soft restraints are not applied to the patient's extremities during a seizure. The caregiver should clear the immediate area to prevent encountering objects that may cause harm or bruising.

In which order do electrical impulses travel through the heart?

1. SA node 2. Internodal pathways 3. Atrioventricular node 4. Bundle of His 5. Purkinje fibers The conduction system of the heart consists of specialized neuromuscular tissue. The electrical impulse of the heart begins at the sinoatrial node in the upper right atrium. This impulse travels through the intermodal fibers and spreads over the atrial musculature. This causes atrial contraction. The impulse then reaches the atrioventricular (AV) node. From the AV node, the impulse moves down through the bundle of His and ends at the Purkinje fibers. Impulses from the Purkinje fibers cause ventricular contractions.

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

1. turn the defibrillator on and select the proper energy level 2. check to see that the synchronizer switch is turned off 3. apply conductive materials to the chest 4. charge the defibrillator using the button on the defibrillator of the paddles 5/ positions the paddles firmly on the chest wall over the conductive material 6. call and look to see that everyone is all clear 7. deliver the charge by depressing buttons on both paddles simultaneously

Which respiratory rate would the nurse anticipate when assessing a patient who is developing pulmonary edema?

32 to 36 breaths/min A respiratory rate higher than 30 breaths/min is often found in patients with pulmonary edema. A patient experiences dyspnea and orthopnea as a result of the accumulation of edematous fluid in the lung tissues, which affects the patient's respiratory rate. Respiratory rates in the ranges of 10 to 24 breaths/min indicate normal respiration.

A patient has an atrial rate of 450 beats per minute and a ventricular rate of 150 beats per minute. Which condition is the patient likely experiencing?

A fib

A patient develops symptomatic sinus tachycardia. Which drug will likely be included in the patient's treatment plan?

Adenosine Hypotension, dizziness, and dyspnea are symptoms of sinus tachycardia. Sinus tachycardia manifests as increased heart rate from 101 beats/minute to 180 beats/minute. Adenosine is used in the treatment of sinus tachycardia. Adenosine decreases the heart rate caused by inhibition of the vagus nerve and myocardial oxygen consumption.

For the patient receiving initial medications for treatment of multiple sclerosis, which medication would the nurse associate with the patient's reports of flu-like symptoms, depressed feelings, and frequent thoughts of committing suicide?

B-1a interferon (Rebif)

which action would the nurse instruct the patient to perform when prescribed phenytoin (Dilantin) for seizures?

Brush your teeth at least twice per day To prevent gingival hyperplasia, the patient should brush twice per day with a soft-bristled toothbrush and visit the dentist twice per year. This condition does not indicate the need for an antifungal solution

Which classic symptom of amyotrophic lateral sclerosis (ALS) would the nurse expect to identify when performing an assessment?

Dysphagia Weakness of the muscles of the legs that progresses to weakness in the upper extremities, dysarthria (difficulty in speech), and dysphagia (difficulty swallowing) are all classic symptoms of ALS. Although dyspnea and dysuria may be present in later stages of ALS, they are not classic symptoms of the disease.

Huntington's disease

Huntington's disease is a genetically transmitted, autosomal dominant disorder characterized by chorea movements and cognitive and psychiatric disorders.

A patient diagnosed with heart failure experiences fatigue. Which factor causes the fatigue?

Impaired perfusion of vital organs Fatigue is one of the early signs of heart failure. As a result of heart failure, there is inadequate blood circulation, leading to decreased perfusion to the vital organs. Impaired functioning of the vital organs may lead to fatigue. Cardiac output decreases in heart failure, depriving the body tissues of oxygen and nutrients, leading to fatigue. Inadequate blood supply results in inadequate oxygenation of the tissue and causes fatigue when the oxygen demands are not met. Hemoglobin levels are low in heart failure, leading to anemia. A decreased oxygen-carrying capacity of the blood also results in fatigue

Which assessment finding is consistent with right-sided heart failure (HF)?

JVD JVD is a sign of right-sided HF. Presence of S3 and S4 heart sounds, PND, and displacement of the PMI are all signs/symptoms of left-sided HF.

Which medication overdose may lead to paradoxical intoxication in a patient with parkinsonism?

Levodopa (L-dopa) Paradoxical intoxication is the aggravation, rather than relief, of symptoms. This condition is mainly due to the excessive use of dopaminergic drugs such as levodopa.

If a patient has Parkinson's disease, which patient reaction would the nurse expect when performing a pull test by standing behind the patient and giving a tug backward on the patient's shoulders?

Loses balance and falls backward In a pull test, when the examiner stands behind the patient and gives a tug backward on the shoulder, the patient loses balance and falls backward. This reaction indicates postural instability, a common feature in Parkinson's disease.

Which goal is a primary goal for a patient who has chronic heart failure?

Maximizing cardiac output

Which drug is likely to be prescribed to a patient with heart failure (HF) to treat the compensatory increase in the heart rate and renin release?

Metoprolol Metoprolol is a β-adrenergic receptor blocker (β-blocker) that helps prevent an increase in the heart rate and renin release by inhibiting the sympathetic nervous system

Multiple sclerosis (MS)

Multiple sclerosis is a chronic progressive degenerative disorder of the central nervous system characterized by progressive, chronic demyelination of nerve fibers of the spinal cord and brain.

Which medication classification would the nurse expect of a new medication prescribed to treat the major symptoms of a patient's multiple sclerosis (MS)?

Muscle relaxant MS causes muscle spasticity as loss of the myelin sheath progresses. Muscle relaxants ease these spasms.

For the patient who receives scheduled doses of phenytoin (Dilantin) and begins to experience diplopia, the nurse would immediately determine the presence of which clinical manifestation?

Nystagmus or confusion Diplopia is a sign of phenytoin toxicity. The nurse should assess for other signs of toxicity, which include neurologic changes, such as nystagmus, ataxia, confusion, dizziness, or slurred speech.

Which term is used to describe difficulty breathing when lying down?

Orthopnea Orthopnea refers to dyspnea when recumbent (lying down). Dyspnea refers to difficulty breathing. Bradypnea is the term for abnormally slow breathing. PND is episodic sudden dyspnea that wakes a patient at night.

A patient is diagnosed with left-sided heart failure. Which assessment finding would the nurse expect?

Orthopnea Orthopnea, difficulty breathing except when sitting or standing, is a symptom of advanced heart failure, especially left-sided failure. When the heart fails as a pump, blood backs up into the lungs, causing fluid to leak from the alveolar membrane. As this process continues, pulmonary edema may develop. Patients may experience hypotension or hypertension, depending on the severity of the disease. Pulsating neck veins and edema in the lower extremities are characteristics of right-sided heart failure.

Which neurodegenerative disorder has the characteristics of rigidity and bradykinesia?

Parkinson's disease Parkinson's disease is a chronic, progressive neurodegenerative disorder characterized by an increased muscle tone (known as rigidity), slowness in the initiation and execution of movement (known as bradykinesia), tremors, and gait disturbances.

When evaluating the presence of an initial symptom of Parkinson's disease, which clinical manifestation would the nurse evaluate?

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

Which clinical manifestation occurs with left-sided heart failure (HF) but not with right-sided HF?

Pink sputum Frothy, pink-tinged sputum is a characteristic symptom associated with left-sided HF. Fatigue and anxiety are present as a common symptom both in right-sided and left-sided HF. Anorexia (loss of appetite) is exclusively a symptom of right-sided HF.

The assessment findings of a patient with myocardial infarction (MI) include jugular venous distention, weight gain, peripheral edema, and a heart rate of 108 beats/min. Which complication would the nurse suspect?

Right sided HF MI is a primary cause of HF. Jugular venous distention, weight gain, peripheral edema, and increased heart rate are manifestations of right-sided HF, not left-sided HF, ADHF, or chronic HF.

Which area of the body would best show accumulation of edema in a patient with heart failure (HF) who spends most of the time in bed?

Sacrum In patients with HF who spend a great deal of time in bed, it would be important to assess the sacral area for edema. Edema related to HF may also be found in the feet, lungs, and abdomen. But in this patient, given the history of bed rest, the sacrum will be the most accurate area to assess.

A patient's electrocardiogram (ECG) shows a heart rate of 150 beats/minute and a normal P wave preceding each QRS complex. Which interpretation would the nurse make of these findings?

Sinus tachycardia Sinus tachycardia includes a heart rate of 101 beats to 180 beats per minute. The electrocardiographic study of sinus tachycardia shows a normal P wave preceding each QRS complex with normal time and duration. In atrial fibrillation, the P waves are chaotic and fibrillatory and the QRS complex is normal. The electrocardiographic study of ventricular fibrillation elicits the absence of P waves, and the PR interval and QRS interval cannot be measured. In premature atrial contraction, there are distorted P waves in the ECG.

A patient is admitted to an intensive care unit in stable condition with suspected acute pulmonary embolism (PE). The nurse prepares for the administration of which medication?

Subcutaneous enoxaparin Immediate anticoagulation is required for patients with PE. Subcutaneous administration of low-molecular-weight heparin (LMWH) (e.g., enoxaparin [Lovenox]) or fragmin [Dalteparin] or fondaparinux) is the recommended treatment for patients with acute PE. Subcutaneous administration of LMWH has been found to be safer and more effective than the use of unfractionated heparin.

Which treatment option would the nurse associate with the patient who was received in the emergency department in an unconscious state, who has a routine prescription of gabapentin (Neurontin) for a history of epilepsy, and who is experiencing recurring seizures in rapid succession?

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

The patient with Parkinson's disease lost 35 pounds (15.9 kg) over the last two months, and a swallow study indicates ability to swallow without aspiration. Which intervention would the nurse discuss with the patient and spouse to improve nutritional intake?

allow adequate time for the patient to eat each of six small meals Allowing adequate time for the patient to eat each of six small meals will limit frustration and improve overall intake. Six small feedings may improve intake, but eating every two hours would exhaust the patient. Protein impairs the absorption of levodopa, so the best practice is to avoid large amounts of protein when administering carbidopa/levodopa. Foods should be easily chewable and dissected into small bites to increase the overall intake.

A patient on a cardiac unit is shivering. Which finding would the nurse expect to see on the patient's electrocardiogram (ECG) tracing?

artifact An artifact is a distortion of the baseline and waveforms seen on the ECG. If the patient is shivering or shows any muscle activity, accurate interpretation of the heart rhythm is difficult, and artifacts can occur on the monitor. Asystole is the absence of all cardiac electrical activity. Atrial flutter occurs in chronic lung disease or hypertension. Junctional dysrhythmias are associated with an electrolyte imbalance or rheumatic heart disease.

For the patient with multiple sclerosis, which action would the nurse classify as a priorityintervention when developing the patient's plan of care?

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

The nurse monitoring the electrocardiogram (ECG) of a patient with hyperthyroidism observes regular, sawtooth-shaped flutter waves with an atrial rate of 250 beats/minute. Which term would the nurse use to document this pattern?

atrial flutter

Which heart rate would the nurse expect in a patient with paroxysmal supraventricular tachycardia (PSVT)?

between 151 and 220

The nurse provides education to a group of nursing students about nonemergent synchronized cardioversion. Which statement made by a student indicates effective learning?

cardio version is designed to stop the heart briefly Synchronized cardioversion is designed to send an electrical shock through the heart on the R wave. This stops the heart momentarily, allowing it to convert back to a normal sinus rhythm. In a nonemergent situation, sedation medicine is given before the procedure because of the pain of the electrical current passing through the chest wall

When visiting a patient prescribed phenytoin (Dilantin) for seizures, which instruction would the nurse provide the patient to prevent precipitation of seizures?

do not stop the drug abruptly without consulting the health care provider Phenytoin is an antiseizure drug. Abrupt withdrawal of the drug after long-term use may precipitate seizures; therefore the patient should not stop the drug without consulting the health care provider. Unusual hair growth and gingival hyperplasia are side effects of antiseizure drugs and are not relevant in preventing precipitation of seizures. Maintaining a healthy lifestyle is a general measure to keep healthy and may not contribute to prevention of precipitation of seizures.

Which information would the nurse relay to the patient with a newly prescribed medication, carbamazepine (Tegretol), for treatment of a new-onset seizure disorder?

do not take this medication with grapefruit or grapefruit juice Grapefruit inhibits the activity of the gastrointestinal enzyme that breaks down this medication so that more of the drug is in the body, and sometimes dangerously high amounts can enter the bloodstream. Administer carbamazepine to treat generalized tonic-clonic and partial seizures. Instruct patients to report any type of visual abnormalities. Antiseizure drugs do not cure the condition but help to prevent seizures with a minimum of side effects.

An echocardiogram for a patient indicates enlarged ventricles of the heart. Which condition could be the cause of the cardiac dilation?

elevated pressure in the ventricles Cardiac dilation is an enlargement of the heart chambers, usually the ventricles; it occurs when pressure in the heart chambers is elevated over time. Hypertrophy is an increase in the muscle mass and thickness of the cardiac wall in response to overwork and strain. When the sympathetic nervous system activation is increased, there is an increased release of catecholamines, which results in an increased heart rate.

Which medication would the nurse associate with the primary drug of choice when treating tonic-clonic seizures?

phenytoin (Dilantin)

Which medication, taken by a patient with a history of epilepsy, would the nurse associate with gingival enlargement?

phenytoin (Dilantin) Phenytoin, gabapentin, clonazepam, valproic acid, and carbamazepine are the drugs used in treating epilepsy. Gingival enlargement is a common side effect of phenytoin; therefore a patient with epilepsy who is using phenytoin may experience gingival enlargement

Which seizure phase would the nurse identify when a patient with systemic lupus erythematosus presents to the emergency department with warm skin, pallor, lethargy, and an altered level of consciousness?

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

Which intervention would the nurse implement when a patient experiences a generalized tonic-clonic seizure?

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

A patient with a long history of heart failure qualifies for hospice care. Which goal would the nurse identify?

providing comfort and relieving suffering The central focus of hospice care is the promotion of comfort and the prevention of suffering. Experimental therapies and surgeries are not commonly used in the care of hospice patients. Medications should be continued unless they are not tolerated.

The nurse is caring for a patient with an acute pulmonary embolism (PE). Which nursing intervention would be appropriate for this patient?

providing comfort by elevating the bed to 45 degrees PE is a blockage of the pulmonary artery by mobile clots that lodge at a narrow part of the circulatory system, resulting in dyspnea and hypoxemia. Initially, the nurse should keep the patient on bed rest in a semi-Fowler's position (at an angle of 45 degrees) to facilitate breathing. Fluid balance in the patient is maintained with IV fluids, as this helps to reduce breathlessness in the patient. The patient with bronchiolitis obliterans, not acute PE, is given a rehabilitation program to improve physical endurance. The nurse should provide the patient with support while walking and standing because the patient could have syncope from hypoxemia. The patient with acute PE is initially kept on bedrest, until standing and walking are permitted by the health care provider.

The nurse reviews the teaching plan for a patient with chronic heart failure who is being discharged from the hospital. Which item listed on the plan would the nurse question?

report a weight gain of 5 pounds in two days The patient should be instructed to immediately report a weight gain of 3 pounds in two days or 3 to 5 pounds in a week. Eating small, frequent meals is a component of dietary therapy. The patient should be instructed to receive the annual flu vaccination for health promotion. The patient should be instructed to avoid extremes of heat and cold to prevent stress on the heart.

When planning the care for a patient with multiple sclerosis who has an exacerbation of sensory deficits, for which patient problem would the nurse develop nursing interventions?

risk for injury Multiple sclerosis usually exhibits itself on one side more than the other. Therefore the gait is unsteady, so there is an increase in the patient's fall risks. Acute confusion may be a manifestation experienced by some patients later in the multiple sclerosis disease process.

A male patient with chronic heart failure develops enlarged breasts. Which medication from the patient's medication profile is the likely cause of the patient's condition?

spironolactone Spironolactone, if used for a prolonged period, may cause breast enlargement or gynecomastia in males

Which disorder would the nurse associate with a patient's seizure lasting longer than five minutes and occurring in rapid succession without a return to consciousness between seizures?

status epilepticus Status epilepticus is a state of continuous seizure activity or a condition in which seizures recur in rapid succession without return to consciousness between seizures. Epilepsy is a disorder marked by a continuing predisposition to seizures with neurobiologic, cognitive, psychologic, and social consequences. The characteristics of an absence seizure is a brief staring spell lasting less than 10 seconds. A tonic seizure involves a sudden increase in tone of the exterior muscles that contribute to sudden stiff movements, lasting 20 seconds or less.

A patient with paroxysmal supraventricular tachycardia (PSVT) who is receiving IV adenosine becomes hemodynamically unstable. Which intervention would the nurse expect to be included in the patient's immediate treatment plan?

synchronized cardioversion PSVT is a dysrhythmia starting in an ectopic focus anywhere above the bifurcation of the bundle of His. The standard drug of choice to treat PSVT is IV adenosine. Sometimes the drug therapy is ineffective, and the patient becomes hemodynamically unstable. For patients who are unresponsive to treatment, synchronized cardioversion is used. Synchronized cardioversion is low energy shock, which uses a sensor to deliver electricity that is synchronized with the peak of the QRS complex.

Which condition causes the symptoms of right-sided heart failure?

systemic venous congestion The symptoms of right-sided heart failure are caused by the backup of blood into the venous system. Preload in right-sided heart failure is increased. Cardiac output is decreased in right-sided heart failure. Fluid congestion in the lungs is a symptom of left-sided heart failure

Which instructions would the nurse provide the patient with multiple sclerosis (MS) who received a new prescription for interferon?

this medication often causes patients to experience flu like symptoms Interferon is an immunomodulator medication that treats the disease process and prevents relapses. The medication often causes flu-like symptoms, achiness, and headache, which is treated effectively with mild analgesics such as acetaminophen or ibuprofen. Administer the medication subcutaneously every other day.

Which seizure disorder typically occurs in children and rarely continues beyond adolescence?

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

A patient is scheduled to receive IV adenosine. What action should the nurse take while administering the medication?

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

When assessing a patient for the presence of petit mal, or absence, seizures, which classic sign would the nurse associate with this disorder?

vacant facial expression The patient experiencing a petit mal, or absence, seizure displays a sudden vacant look and usually stares straight ahead. This type of seizure often goes unnoticed by the patient and others.

Defibrillation is indicated for which dysrhythmia?

ventricular fibrillation

Which time period does the T wave in an electrocardiogram (ECG) represent?

ventricular repolarization The ECG is commonly used to detect abnormal heart rhythms and to investigate the cause of chest pains. The T wave in the ECG should be upright; it represents time for ventricular repolarization.