Chapter 42 AH

The nurse has received report on a group of clients. Which client requires the nurse's attention first? 1.Adult who is lethargic after a generalized tonic-clonic seizure 2. Young adult who has experienced four tonic-clonic seizures within the past 30 minutes 3. Middle-aged adult with absence seizures who is staring at a wall and does not respond to questions 4. Older adult with a seizure disorder who has a temperature of 101.9° F (38.8° C)

2

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? (Select all that apply.) 1. Bite block at the bedside 2. Intravenous access 3. Continuous sedation 4. Suction equipment at the bedside 5. Siderails up

2, 4, 5

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? a. Start an intravenous (IV) line. b. Administer phenytoin (Dilantin). c. Draw the client's blood. d. Establish an airway.

d

A client is admitted with bacterial meningitis. Which nursing intervention is the highest priority for this client? 1. Assessing neurological status at least every 2 to 4 hours 2. Decreasing environmental stimuli 3. Managing pain through drug and nondrug methods 4. Strict monitoring of hourly intake and output

1

The parents of a young child report that their child sometimes stares blankly into space for just a few seconds and then gets very tired. The nurse anticipates that the child will be assessed for which seizure disorder? 1. Absence 2. Myoclonic 3. Simple partial 4. Tonic

1

Which change in the cerebrospinal fluid (CSF) indicates to the nurse that a client may have bacterial meningitis? 1. Cloudy, turbid CSF 2. Decreased white blood cells 3. Decreased protein 4. Increased glucose

1

The nurse is reviewing the history of a client who has been prescribed topiramate (Topamax) for treatment of intractable partial seizures. The nurse plans to contact the health care provider if the client has which condition? 1. Bipolar disorder 2. Diabetes mellitus 3. Glaucoma 4. Hypothyroidism

1.

The nurse is caring for a client who has just had a plaster leg cast applied. The nurse should plan to prevent the development of compartment syndrome by performing which action? 1. Elevate the limb slightly. 2. Elevate the limb above heart level. 3. Keep the leg horizontal and cover the limb with bath blankets. 4. Place the leg in a slightly dependent position, and apply ice to the affected leg.

1. Elevate the limb slightly.

A client who sustained a severe sprain of the ankle is told by the health care provider that the pain experienced is caused by muscle spasm and swelling in the area of the injury. Which interventions should the nurse anticipate will be included in the client's initial plan of care? Select all that apply. 1. Ice bags 2. Elevation 3. Heating pad 4. Compression bandage 5. Range-of-motion exercises

1. Ice bags 2. Elevation 4. Compression bandage

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client? 1. Altered body image 2. Inability to care for self 3. Disruption in coping ability 4. Difficulty maintaining health

1. Altered body image

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data would the nurse evaluate as the most favorable indication of resolution of the fat embolus? 1. Clear mentation 2. Minimal dyspnea 3. Oxygen saturation of 85% 4. Arterial oxygen level of 78 mm Hg

1. Clear mentation'

A home care nurse is providing instructions to a client regarding the use of crutches. The client asks the nurse to demonstrate the method for going down the stairs with the crutches. How should the nurse accurately demonstrate this technique? 1. Crutches and the affected leg down, followed by the unaffected leg 2. Crutches and the unaffected leg down, followed by the affected leg 3. Unaffected leg down first, followed by the crutches and the affected leg 4. Affected leg down first, followed by the crutches and the unaffected leg

1. Crutches and the affected leg down, followed by the unaffected leg

Which cast care instructions should the nurse provide to a client who just had a plaster cast applied to the right forearm? Select all that apply. 1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated. 4. Expect tingling and numbness in the extremity. 5. Use a hair dryer set on a warm to hot setting to dry the cast. 6. Use a soft padded object that will fit under the cast to scratch the skin under the cast.

1. Keep the cast clean and dry. 2. Allow the cast 24 to 72 hours to dry. 3. Keep the cast and extremity elevated.

Which assistive device would the nurse use to reduce surface area and friction when patients are unable to assist with moving up in bed? 1 Arm splints 2 Trapeze bar 3 Full-body sling 4 Trochanter roll

2

Which is the most effective way for a college student to minimize the risk for bacterial meningitis? 1. Avoid large crowds. 2. Get the meningococcal vaccine. 3. Take a daily vitamin. 4. Take prophylactic antibiotics.

2

The nurse is caring for a client diagnosed with partial seizures after encephalitis, who is to receive carbamazepine (Tegretol). The nurse plans to monitor the client for which adverse effects? (Select all that apply.) 1. Alopecia 2. Headaches 3. Dizziness 4. Diplopia 5. Increased blood glucose

2, 3, 4

A home care nurse has instructed a client how to perform the three-point gait with the use of crutches. The nurse observes the client using this gait to ensure correct performance of the maneuvers. Which observation, if made by the nurse, would indicate that the client understands how to perform this type of gait? 1. The client moves both crutches forward and then swings both feet forward to the crutches. 2. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward. 3. The client moves the right crutch forward, along with the left foot, and then brings the right foot and the left crutch forward. 4. The client moves the left crutch forward, along with the right foot, and then brings the left foot and the right crutch forward.

2. The client moves both crutches forward, along with the affected leg, and then moves the unaffected leg forward.

The nurse is developing a plan of care for a client in Buck's traction. The plan of care should include assessing the client for which finding indicating a complication associated with the use of this type of traction? 1. Hypotension 2. Weak pedal pulses 3. Redness at the pin sites 4. Drainage at the pin sites

2. Weak pedal pulses

The nurse has conducted teaching with a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client states that he or she should report which early symptom of compartment syndrome? 1. Cold, bluish-colored fingers 2. Numbness and tingling in the fingers 3. Pain that increases when the arm is dependent 4. Pain that is out of proportion to the severity of the fracture

2.. Numbness and tingling in the fingers

A client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? 1. Administer phenytoin (Dilantin). 2. Draw the client's blood. 3. Assess the need for additional support. 4. Start an intravenous (IV) line.

3

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain? 1. Infection under the cast 2. The anxiety of the client 3. Impaired tissue perfusion 4. The recent occurrence of the fracture

3

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? 1. Apple juice 2. Grape juice 3. Grapefruit juice 4. Milk

3

The nurse is planning discharge teaching for a client diagnosed and treated for compartment syndrome. Which information should the nurse include in the teaching? 1. "A bone fragment has injured the nerve supply in the area." 2. "An injured artery caused impaired arterial perfusion through the compartment." 3. "Bleeding and swelling caused increased pressure in an area that couldn't expand." 4. "The fascia expanded with injury, causing pressure on underlying nerves and muscles."

3. "Bleeding and swelling caused increased pressure in an area that couldn't expand."

The nurse is caring for an older adult who has been placed in Buck's extension traction after a hip fracture. On assessment of the client, the nurse notes that the client is disoriented. What is thebest nursing action based on this information? 1. Apply restraints to the client. 2. Ask the family to stay with the client. 3. Place a clock and calendar in the client's room. 4. Ask the laboratory to perform electrolyte studies.

3. Place a clock and calendar in the client's room.

The nurse is administering the intake assessment for a newly admitted client with a history of seizures. The client suddenly begins to seize. What does the nurse do next? 1. Documents the length and time of the seizure. 2. Forces a tongue blade in the mouth. 3. Restrains the client. 4. Positions the client on the side.

4

A client with diabetes mellitus has had a right below-knee amputation. The nurse would be especially vigilant in monitoring for which of the following because of the client's history of diabetes mellitus? 1. Hemorrhage 2. Edema of residual limb 3. Slight redness of incision 4. Separation of wound edges

4. Separation of wound edges

The nurse is caring for a client who had an above-knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage, which has come off. Which immediate action should the nurse take? 1. Apply ice to the site. 2. Call the health care provider (HCP). 3. Apply a dry sterile dressing and elevate it on one pillow. 4. Rewrap the residual limb with an elastic compression bandage.

4. Rewrap the residual limb with an elastic compression bandage.

A client presents to the clinic with a migraine and is lying in a darkened room with a wet cloth on the head after receiving treatment. In preparation for dismissal home, what does the nurse do next? a. Allow the client to remain undisturbed. d. Assess the client's vital signs. c. Remove the cloth because it can harbor microorganisms. d. Turn on the lights for a neurologic assessment. Allow the client to remain undisturbed.

A The next action by the nurse is to allow the client to remain undisturbed. The client may be able to alleviate pain by lying down in a darkened room with a cool cloth on his or her forehead. If the client falls asleep, he or she would remain undisturbed until awakening.Assessing the client's vital signs, although important, will disturb the client unnecessarily. A cool cloth is helpful for the client with a migraine and does not present enough of a risk that it would be removed. Turning on the lights for a neurologic assessment is not appropriate because light can cause the migraine to worsen.

Which action will the public health nurse take to reduce the incidence of epidemic encephalitis in a community? a. Encourage the use of effective insect repellents during mosquito season. b. Remind patients that most cases of viral encephalitis can be cared for at home. c. Teach about the importance of prophylactic antibiotics after exposure to encephalitis. d. Arrange for screening of school-age children for West Nile virus during the school year.

ANS: A Epidemic encephalitis is usually spread by mosquitoes and ticks. Use of insect repellent is effective in reducing risk. Encephalitis frequently requires that the patient be hospitalized in an intensive care unit during the initial stages. Antibiotic prophylaxis is not used to prevent encephalitis because most encephalitis is viral. West Nile virus is most common in adults over age 50 during the summer and early fall

A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. Do you live in a crowded residence? b. When was your last tetanus vaccination? c. Have you had any viral infections recently? d. Have you traveled out of the country in the last month?

ANS: A Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of highdensity population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.

A patient who has bacterial meningitis is disoriented and anxious. Which nursing action will be included in the plan of care? a. Encourage family members to remain at the bedside. b. Apply soft restraints to protect the patient from injury. c. Keep the room well-lighted to improve patient orientation. d. Minimize contact with the patient to decrease sensory input.

ANS: A Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The patient requires frequent assessment for complications; the use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

A nurse assesses an older adult client who was admitted 2 days ago with a fractured hip. The nurse notes that the client is confused and restless. The clients vital signs are heart rate 98 beats/min, respiratory rate 32 breaths/min, blood pressure 132/78 mm Hg, and SpO2 88%. Which action should the nurse take first? a. Administer oxygen via nasal cannula. b. Re-position to a high-Fowlers position. c. Increase the intravenous flow rate. d. Assess response to pain medications.

ANS: A The client is at high risk for a fat embolism and has some of the clinical manifestations of altered mental status and dyspnea. Although this is a life-threatening emergency, the nurse should take the time to administer oxygen first and then notify the health care provider. Oxygen administration can reduce the risk for cerebral damage from hypoxia. The nurse would not restrain a client who is confused without further assessment and orders. Sitting the client in a high-Fowlers position will not decrease hypoxia related to a fat embolism. The IV rate is not related. Pain medication most likely would not cause the client to be restless.

An emergency department nurse cares for a client who sustained a crush injury to the right lower leg. The client reports numbness and tingling in the affected leg. Which action should the nurse take first? a. Assess the pedal pulses. b. Apply oxygen by nasal cannula. c. Increase the IV flow rate. d. Loosen the traction.

ANS: A These symptoms represent early warning signs of acute compartment syndrome. In acute compartment syndrome, sensory deficits such as paresthesias precede changes in vascular or motor signs. If the nurse finds a decrease in pedal pulses, the health care provider should be notified as soon as possible. Vital signs need to be obtained to determine if oxygen and intravenous fluids are necessary. Traction, if implemented, should never be loosened without a providers prescription.

The nurse is assessing a client for chronic osteomyelitis. Which features distinguish this from the acute form of the disease? (Select all that apply.) a. Draining sinus tracts b. High fevers c. Presence of foot ulcers d. Swelling and redness e. Tenderness or pain

ANS: A, C Draining sinus tracts and foot ulcers are seen in chronic osteomyelitis. High fever, swelling, and redness are more often seen in acute osteomyelitis. Pain or tenderness can be in either case.

1. A 27-year-old patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room (select all that apply)? a. Side-rail pads b. Tongue blade c. Oxygen mask d. Suction tubing e. Urinary catheter f. Nasogastric tube

ANS: A, C, D The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Use of tongue blades during a seizure is contraindicated. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. A urinary catheter is not required unless there is urinary retention.

A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells

ANS: A, C, D In viral meningitis, CSF fluid is clear, protein levels are slightly increased, and glucose levels are normal. Viral meningitis does not cause cloudiness or increased turbidity of CSF. In bacterial meningitis, the presence of bacteria and white blood cells causes the fluid to be cloudy.

A client with chronic osteomyelitis is being discharged from the hospital. What information is important for the nurse to teach this client and family? (Select all that apply.) a. Adherence to the antibiotic regimen b. Correct intramuscular injection technique c. Eating high-protein and high-carbohydrate foods d. Keeping daily follow-up appointments e. Proper use of the intravenous equipment

ANS: A, C, E The client going home with chronic osteomyelitis will need long-term antibiotic therapyfirst intravenous, then oral. The client needs education on how to properly administer IV antibiotics, care for the IV line, adhere to the regimen, and eat a healthy diet to encourage wound healing. The antibiotics are not given by IM injection. The client does not need daily follow-up.

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

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

A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 353 and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure

ANS: B Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in

A nurse cares for a client with a fractured fibula. Which assessment should alert the nurse to take immediate action? a. Pain of 4 on a scale of 0 to 10 b. Numbness in the extremity c. Swollen extremity at the injury site d. Feeling cold while lying in bed

ANS: B Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 429 The client with numbness and/or tingling of the extremity may be displaying the first signs of acute compartment syndrome. This is an acute problem that requires immediate intervention because of possible decreased circulation. Moderate pain and swelling is an expected assessment after a fracture. These findings can be treated with comfort measures. Being cold can be treated with additional blankets or by increasing the temperature of the room.

A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia

ANS: B, D, E

A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) a. Intermittent rigidity b. Lip smacking c. Sudden loss of muscle tone d. Brief jerking of the extremities e. Picking at clothing f. Patting of the hand on the leg

ANS: B, E, F

The nurse reviews the health history of a client with acute osteomyelitis. Which findings might have contributed to the diagnosis? (Select all that apply.) a. Recent dental work b. Urinary tract infection c. Pregnancy d. Age e. Hemodialysis f. Gastrointestinal infection

ANS: B, E, F Poor dental hygiene and gum infection (not necessarily recent dental work), urinary tract infection, hemodialysis, and Salmonella infection of the gastrointestinal tract can be sources of infection and, consequently, osteomyelitis. Pregnancy and advancing age are not necessarily precursors to osteomyelitis, even though urinary tract infection leading to osteomyelitis is common in older men.

While caring for a patient who has just been admitted with meningococcal meningitis, the RN observes all of the following. Which one requires action by the RN? a. The bedrails at the head and foot of the bed are both elevated. b. The patient receives a regular diet from the dietary department. c. The nursing assistant goes into the patient's room without a mask. d. The lights in the patient's room are turned off and the blinds are shut.

ANS: C Meningococcal meningitis is spread by respiratory secretions, so it is important to maintain respiratory isolation as well as standard precautions. Because the patient may be confused and weak, bedrails should be elevated at both the food and head of the bed. Low light levels in the room decrease pain caused by photophobia. Nutrition is an important aspect of care in a patient with meningitis.

A client who has been diagnosed with osteomyelitis is beginning antibiotic therapy. Which information does the nurse include in the client's teaching plan? a. Needing a consultation with a surgeon b. Continuing on Contact Isolation at home c. Remaining in the hospital for the rest of the treatment d. Receiving antibiotic treatment at home from the home health nurse

ANS: D

The nurse assesses for which clinical manifestations in the client with suspected encephalitis? a. Fever of 101° F (38.3° C) b. Nausea and vomiting c. Hypoactive deep tendon reflexes d. Pain on flexion of the neck

ANS: D

After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. Test Bank - Medical-Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 354 b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.

ANS: D Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.

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

ANS: D The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy. DIF: Applying/Application REF: 860

A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves

ANS: D, E Meningeal meningitis is spread via saliva and droplets, and Droplet Precautions are necessary. Caregivers should wear a surgical mask when within 6 feet of the client and should continue to use Standard Precautions, including gloves. A particulate respirator, an isolation gown, and shoe covers are not necessary for Droplet Precautions.

A nurse is caring for a client being treated for fat embolus after multiple fractures. Which of the following data would the nurse evaluate as the most favorable indication of resolution of fat embolus? a. Minimal dyspnea b. Clear chest radiography c. Oxygen saturation of 85% d. Arterial oxygen of 78 mm Hg

ANSWER: B - A clear chest radiograph is a good indicator that a fat embolus is resolving. When fat embolism is resolving. When fat embolism occurs, the client radiograph has a "snowstorm" appearance.

A patient with possible viral meningitis is admitted to the nursing unit after lumbar puncture was performed in the emergency department. Which action prescribed by the health care provider should the nurse question? a. Elevate the head of the bed 20 degrees. b. Restrict oral fluids to 1000 mL daily. c. Administer ceftriaxone (Rocephin) 1 g IV every 12 hours. d. Give ibuprofen (Motrin) 400 mg every 6 hours as needed for headache.

B

The nurse is planning discharge instructions for the client with osteomyelitis. What instructions should the nurse include in the discharge teaching? a) "You need to perform weight-bearing exercises twice a week." b) "You will receive IV antibiotics for 3 to 6 weeks." c) "You need to limit the amount of protein and calcium in your diet." d) "Use your continuous passive motion machine (CPM) 2 hours each day.""You will receive IV antibiotics for 3 to 6 weeks."

B Explanation: Treatment of osteomyelitis requires IV antibiotics for 3 to 6 weeks.

Classic symptoms of bacterial meningitis include a. papilledema and psychomotor seizures b. high fever, nuchal rigidity, and severe headache c. behavioral changes with memory loss and lethargy d. positive Kernig's and Brudzinski's signs and hemiparesis

B. High fever, severe headache, nuchal rigidity, and positive Brudzinski's and Kernig's signs are such classic symptoms of meningitis that they are usually considered diagnostic for meningitis. Other symptoms, such as papilledema, generalized seizures, hemiparesis, and decreased LOC, may occur as complications of increased ICP and cranial nerve dysfunction.

A patient admitted with bacterial meningitis and a temperature of 102° F (38.8° C) has orders for all of these collaborative interventions. Which action should the nurse take first? a. Administer ceftizoxime (Cefizox) 1 g IV. b. Use a cooling blanket to lower temperature. c. Swap the nasopharyngeal mucosa for cultures. d. Give acetaminophen (Tylenol) 650 mg PO.

C

Nurse on clinical unit is assigned to four patients. Which patient should she assess first? a. Patient with a skull fracture whose nose is bleeding b. Older patient with a stroke who is confused and whose daughter is present c. Patient with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale d. Patient who had a craniotomy for a brain tumor who now 3 days postoperative had had continued vomiting

C

The community health nurse is developing a program to decrease the incidence of meningitis in adolescents and young adults. Which nursing action is most important? a. Vaccinate 11- and 12-year-old children against Haemophilus influenzae. b. Emphasize the importance of hand washing to prevent spread of infection. c. Immunize adolescents and college freshman against Neisseria meningitides. d. Encourage adolescents and young adults to avoid crowded areas in the winter.

C

A 68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? A. Codeine B. Phenytoin (Dilantin) C. Ceftriaxone (Rocephin) D. Acetaminophen (Tylenol)

C Bacterial meningitis is a medical emergency. When meningitis is suspected, antibiotic therapy (e.g., ceftriaxone) is instituted immediately after the collection of specimens for cultures, and even before the diagnosis is confirmed. Dexamethasone may also be prescribed before or with the first dose of antibiotics. The nurse should collaborate with the health care provider to manage the headache (with codeine), fever (with acetaminophen), and seizures (with phenytoin).

Which patient is considered to be in status​ epilepticus? A.The patient who has two or more seizures consecutively with a period of responsiveness between them B.The patient with a history of​ medication-controlled seizures who experiences a generalized seizure C.The patient who remains unresponsive after the seizure D.The patient who suffers a seizure that lasts 10 minutes

Correct is D

A patient with a fracture of the femur has the extremity in skeletal traction and is encouraged to use an overhead trapeze apparatus. The nurse explains that the primary purpose of the overhead trapeze is what? a. To assist with leg exercises b. To enhance breathing and lung expansion c. To promote circulation throughout the body d. To facilitate independent movement while the patient is in bed

D

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? A. Tonic spasms of the legs B. Curling in a fetal position C. Arching of the neck and back D. Resistance to flexion of the neck

D

When assessing a patient with bacterial meningitis, the nurse obtains the following data. Which finding should be reported immediately to the health care provider? a. The patient has a positive Kernig's sign. b. The patient complains of having a stiff neck. c. The patient's temperature is 101° F (38.3° C). d. The patient's blood pressure is 86/42 mm Hg.

D

Which nursing action does the nurse on the orthopedic unit plan to delegate to unlicensed assistive personnel (UAP)? A. Remove the wound drain for a client who had an open reduction of a hip fracture 3 days ago. B. Assess for bruising on a client who is receiving warfarin (Coumadin) to prevent deep vein thrombosis. C. Teach a client with a right ankle fracture how to use crutches when transferring and ambulating. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. D. Check the vital signs for a client who was admitted after a total knee replacement 3 hours ago. Correct

D Vital sign assessment is a skill that is within the role of the UAP. Removing a wound drain, assessment, and client teaching are nursing actions that require broader education and are within the scope of practice of licensed nursing staff.

A patient with a long leg cast reports pain in the toes. The nurse discovers that the toes are pale and cool to the touch with intact pulses and minimal neuropathy. The findings indicate that the patient may be experiencing what? a. Osteomyelitis B. A fat embolism c. A pressure ulcer D. Compartment syndrome

D. Rationale Compartment syndrome is the progressive compromise of neurovascular function of tissue in a confined space such as a cast. It may also result from circumferential inflammation around an extremity. The earliest sign is paresthesias, followed by pain, pressure resulting from edema, pallor, paralysis, and absence of pulse. (Absence of the peripheral pulse is a late and ominous sign.) A pressure ulcer is caused by decreased circulation due to pressure, tissue hypoxia, and destruction. Osteomyelitis is an infectious process within the bone. A fat embolism is an acute event in which fat globules released into circulation obstruct pulmonary circulation. It is seen with fractures of long bones such as the femur.

client admitted with cerebral edema suddenly begins to have a seizure while the nurse is in the room. What does the nurse do first? Administer phenytoin (Dilantin). Draw the client's blood. Establish an airway. Start an intravenous (IV) line.

Establish an airway. When a client admitted with cerebral edema begins to have a seizure, the nurse must first establish an airway. The primary goal is to open and maintain an airway and then assess the client for the need of additional support during the seizure.Phenytoin (Dilantin) is administered to prevent the recurrence of seizures, not to treat a seizure already underway. Drawing blood or starting an IV is not the priority in this situation. Remember the ABCs during an emergency situation.

The nurse is providing medication instructions for a client for whom phenytoin (Dilantin) has been ordered for treatment of epilepsy. The nurse instructs the client to avoid which beverage? Apple juice Grape juice Grapefruit juice Prune juice

Grapefruit juice The nurse instructs the client taking phenytoin for epilepsy to avoid taking grapefruit juice. Some citrus fruits and juices, like grapefruit juice, can interfere with the metabolism of phenytoin potentially leading to an increased blood level and toxicity.Apple, grape, and prune juices are not contraindicated for a client taking phenytoin (Dilan

A client has been admitted with new-onset status epilepticus. Which seizure precautions does the nurse put in place? Select all that apply. a. Bite block at the bedside b. Intravenous access (IV) c. Continuous sedation d. Suction equipment at the bedside e. Siderails raised

b, d, e, Seizure precautions the nurse institutes for an admitted client with new-onset status epilepticus include IV access, suctioning equipment at the bedside and raised siderails. IV access is needed to administer medications. Suctioning equipment must be available to suction secretions and facilitate an open airway during a seizure. Raised, padded siderails may be used to protect the client from falling out of bed during a seizure.Bite blocks or padded tongue blades would not be used because the client's jaw may clench, causing teeth to break and possibly obstructing the airway. Continuous sedation is a medical intervention and not a seizure precaution.