Nur 242 exam 5

Which response would the nurse make to the son who says, "I should never have allowed my father to live alone like he wanted to because he has Alzheimer disease. I'm to blame! He didn't even recognize me"?

This must be a difficult time for both of you. Please share some of your other observations with us—that will help us plan his care."

To best address the functional and behavioral changes associated with a client's early Alzheimer disease, which action would the nurse encourage the daughter to do?

Post a schedule of the client's daily activities

A client with type 2 diabetes is admitted to the ambulatory surgery unit for elective cataract surgery. Before surgery the client asks the nurse, "How will my diabetes be managed while I am here?" Which is the best response by the nurse?

I'm not quite certain I understand what you are asking."

The nurse notes that a child is exhibiting signs of cerebral palsy. At which age are these signs usually first noticeable?

12 months

A child with a seizure disorder has a generalized seizure shortly after admission to the hospital. Which nursing actions are most appropriate? Select all that apply. One, some, or all responses may be correct.

Assessing the seizure, turning the child on the side, pulling the padded side rails up

Which approach would the nurse use for a nursing home client with Alzheimer disease who is confused, agitated, and at times unaware of the presence of others?

Arranging for the constant presence of a staff member

A client who has a history of seizures is scheduled for an arteriogram at 10:00 AM and is to have nothing by mouth before the test. The client is scheduled to receive an anticonvulsant medication at 9:00 AM. Which action would the nurse take?

Ask the health care provider to prescribe an alternative

Upon entering a client's room, the nurse sees the client exhibiting seizure activity. Which is the first action the nurse would take?

Assess the client's airway

Which outcome is the priority for a client with a migraine?

To decrease pain

When would the risk of another seizure in a client with eclampsia decrease?

48 hours postpartum

Phenytoin suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How many milliliters will the nurse administer?__ mL

8 ml

Which type of cerebral palsy (CP) is associated with slow writhing movements?

Athetoidg

Which approach would the nurse use for a client with Alzheimer disease who expresses fear and anxiety upon admission to a long-term care facility?

Reassuring the client with the presence of 1 or 2 staff members

A client with severe abdominal pain is on meperidine treatment and later develops seizures. Which intervention is given highest priority?

Stop administration of meperidine

A 6-year-old child has not been feeling well, is weak and lethargic, and has a poor appetite, headaches, and smoky-colored urine. Which additional information would the nurse obtain that will aid the child's diagnosis?

Strep throat in the past 2 weeksThe smoky urine and the stated symptoms would lead the nurse to suspect glomerulonephritis, which usually occurs after a recent streptococcal infection.

Which instruction would the nurse give to a client with reduced sensory perception?

Use a bath thermometer

Topiramate (Topamax)

Used to treat epilepsy, topiramate may have teratogenic effects that cause a newborn to develop a cleft lip with cleft palate. Carbamazepine and valproic acid may cause fetal neural tube defects. Phenytoin may cause fetal central nervous system defects.

Agnosia

loss of ability to recognize importance of sensory impressions

macular degeneration

loss of central vision

A child with cerebral palsy (CP) is to be taught the four-point alternate crutch gait. The parents ask why this gait was chosen. How would the nurse respond?

provides for equal but partial weight-bearing on each limb."

A client with Alzheimer disease has been taking galantamine and is newly prescribed paroxetine for depression. Which effect would the nurse assess for in the client?

Additive

A client with epilepsy reports diffuse redness and large blisters on the buccal mucosa. Administration of which medication could be a possible reason for the client's condition?

Barbiturates

A client has a tonic-clonic seizure. The nurse anticipates that the health care provider will prescribe the intravenous administration of which medication?

Diazepam

A client on bupropion therapy for depression experiences seizures. Which actions are used to reduce the risk for seizures? Select all that apply. One, some, or all responses may be correct.

Discouraging rapid dose titration, avoiding administration of the medication with paroxetine, avoiding concomitant use of fluoxetine

Which action would the nurse take first for a client complaining of headaches with a blood pressure (BP) at 172/114 mm Hg?

Elevate the head of the bed, provide reassurance, and reassess the BP

Which ability would the nurse expect of a client in the middle stages of Alzheimer disease to be able to do?

Recall events from the past

Which education would the nurse provide about the occurrence of febrile seizures?

They may occur in minor illnesses

The nurse understands which antiepileptic medication would be used as the first-line treatment for absence seizures?

Valproic acid

Which medication would the nurse recognize as being contraindicated for use in clients with eating and seizure disorders?

Bupropion

The nurse is providing instructions to a client who has glaucoma. Which statements by the client indicate that the nurse needs to intervene? Select all that apply. One, some, or all responses may be correct.

I can lift objects than weight more than 10lbs, I should keep my head in dependent position

Which condition can cause a client severe pain after a cataract extraction?

Hemorrhage into the eye

The nurse leader suffers from headaches, hypertension, and gastrointestinal problems. Which statement by the leader reflects an appropriate way to manage the stress?

I will get enough sleep."

Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility?

Occurs with a transfer to new surroundings

Which piece of equipment will the nurse remove from the bedside of a client on seizure precautions?

Padded tongue blade

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease?

Routines provide stability for clients with neurocognitive disorders

Which conclusion would the home care nurse make regarding an older adult client with mild Alzheimer disease?

Should be allowed to function independently if therapeutically possible

Which description of symptoms is consistent with dementia of the Alzheimer type?

Symptoms reflect progressive disintegration

Which would the nurse determine before preparing a child with cerebral palsy (CP) for crutch-walking?

Weight-bearing ability of the child's four extremities. The choice of gait is based on the weight-bearing capabilities of each of the four extremities. Assessment of the extremities takes priority over assessment of the trunk. The child with CP uses upper extremity strength for crutch control and lower extremity strength to facilitate some movement.

A client with a seizure disorder is receiving phenytoin and phenobarbital. Which client statement indicates that the instructions regarding the medications are understood?

"Stopping the medications can cause continuous seizures and i may die"

Which care service can the nurse suggest to the daughter of a client with Alzheimer disease who expresses the need for assistance with care for a few hours a couple of days a week?

Adult day care

Which parental statements would the nurse recognize as signs that an infant may need to be evaluated for cerebral palsy? Select all that apply. One, some, or all responses may be correct.

All of my other children were sitting alone by this age. This baby doesn't seem to be anywhere near sitting alone. My baby was able to turn from front to back by 2 months of age."

Which action would the nurse take for an older adult resident with Alzheimer disease who often talks about the "good old days" at the ranch?

Allowing the resident to reminisce about the past and listening with interest

Which nursing intervention is the most effective in preventing a seizure in a client with severe preeclampsia

Controlling external stimuli

Which nursing interventions would be beneficial to the pregnant client receiving antiseizure medication therapy? Select all that apply. One, some, or all responses may be correct.

Determine when the medications were taken. Consult a gynecologist to determine the type of malformation expected.Explain that the risk of malformation is minimal and can be corrected later.

Which description is correct for Alzheimer disease?

Is a slow, relentless deterioration of the mind

nurse is planning to teach the four-point alternate crutch gait to a 9-year-old child with cerebral palsy. How would the nurse explain this choice to the parents?

It provides for equal but partial weight bearing on each limb

A client has a tonic-clonic seizure caused by an overdose of aspirin. Which action would the nurse take next?

Monitor vital signs every 15 minutes

Which approach would the nurse use for an older adult client with Alzheimer disease who frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause?

Providing nursing care when the client is receptive

How would the nurse describe the clonic phase of a tonic-clonic seizure?

Rhythmic body jerking

Which explanation best describes what is known about the pathophysiology of dementia of the Alzheimer type?

The prescence of amyloid plaques is associated with brain tissue destruction.

During a seizure, a client had sudden loss of muscle tone that lasted for a few seconds followed by confusion. Which statement about this type of seizures is true? Select all that apply. One, some, or all responses may be correc

These seizures increase the risk for injuries from a fall. These seizures are most resistant to medication therapy

Warfarin is prescribed for the client who takes phenytoin for a seizure disorder. Which medication interaction complicates seizure therapy?

Warfarin inhibits the metabolism of phenytoin

After interacting with a client, the nurse thinks the client is in the prodromal phase of a migraine. Which statements made by the client led the nurse to reach this conclusion? Select all that apply. One, some, or all responses may be correct.

I feel drowsy all the time. I feel confused at this point of time. I feel weakness in the left side of my body. he first phase of a migraine headache is called the prodromal phase. In the prodromal phase, a variety of neurological changes are seen. These include drowsiness, acute confusion, vertigo, numbness and tingling of lips or tongue, aphasia, and unilateral weakness. Severe pain over the ear is pain in the templar region and is the second phase of a migraine headache. Throbbing pain in the head occurs in the third phase of a migraine.

The newborn of a lactating woman taking fluoxetine developed tremors, seizures, and fever. Which medication-induced physiological alterations may be responsible for the central nervous system effects of the medication on the neonate?

Immature blood-brain barrier

At which time would the staff begin transfer preparation for an older adult client with Alzheimer disease who is to be transferred from the hospital to a long-term care facility?

Immediately after the client's admission to the hospital

A client is admitted to the emergency department after experiencing a seizure. Which action would the nurse take first?

Obtain a history of seizure type and incidence

A client with epilepsy is prescribed phenytoin for seizure control. Which instruction about phenytoin will the nurse provide during discharge teaching?

"Antiseizure medications will probably be continued for life."

In comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia?

Abrupt onset of symptoms

Which medication would the nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma?

Acetazolamide

aphasia

Aphasia is the term for the loss of language ability, which progresses with the disease

Which medication used in the treatment of clients with glaucoma is a prostaglandin agonist?

Bimatoprost

During a home visit, the nurse discovers that a child in the household who has a disability has been experiencing seizures. The child's parent appears indifferent to the child's physical, emotional, or medical needs and seems to provoke seizure episodes by harsh verbal exchanges with the child. Where would the nurse direct a referral?

Child Protective Services

A child becomes cyanotic during a generalized tonic-clonic seizure. Which is the most appropriate action by the nurse?

Continuing to observe the seizure - the child's status and the progression of the seizure should be monitored; the child will not breathe until the seizure is over, and cyanosis should subside at that time.

Which treatment goal would the nurse emphasize when teaching a client with a diagnosis of open-angle glaucoma?

Control intraocular pressure

Which nursing intervention will be priority when caring for a client with status epilepticus?

Establish an airway

Which signs and symptoms are characteristic of Alzheimer dementia? Select all that apply. One, some, or all responses may be correct.

Forgetfulness, expressive aphasia

Which finding would indicate that a client needs to be evaluated by the health care provider for Alzheimer disease (AD)? Select all that apply. One, some, or all responses may be correct.

Forgets home address

Exposure to which element would be the reason for cataracts in a 36-year-old client who is a glass worker? Select all that apply. One, some, or all responses may be correct.

Heat, metal powder

Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes?

Help the client select appropriate attire and offer to help the client get dressed

Which initial action would the nurse take for a nursing home resident with moderate Alzheimer disease who begins to engage in numerous acting-out behaviors?

Identify the stressors that precipitate the client's behavior

Which information would the nurse include in the teaching plan for a client diagnosed with epilepsy?

Individuals taking phenytoin must floss their teeth regularly.

A preterm neonate admitted to the neonatal intensive care nursery exhibits muscle twitching, seizures, cyanosis, abnormal respirations, and a short, shrill cry. Which complication would the nurse suspect?

Intracranial hemorrhage

A lactating woman with hypertension was diagnosed with a migraine. Which would be the medication combination of choice if she wishes to continue breast-feeding?

Labetalol, sumatriptan

The registered nurse (RN) is delegating tasks to the health care team. Which team member is most likely to achieve an effective outcome in the care of a client who is bedridden for long periods with seizures?

Licensed practical nurse (LPN)

Which finding would the nurse anticipate in the health history of a client who has open-angle (chronic) glaucoma?

Loss of peripheral vision

The registered nurse (RN) is caring for a client with epilepsy. Which tasks given by the RN to assistive personnel indicate active delegation? Select all that apply. One, some, or all responses may be correct.

Passive delegation includes performing tasks based on a position description such as a primary health care provider or pharmacist. The individual functioning in this role performs these tasks through passive delegation. Instructing the LPN to administer diazepam, medication already prescribed by the primary health care provider, is passive delegation. Instructing the LVN to administer sedatives already prescribed by the primary health care provider is passive delegation. Instructing the LPN to monitor vital signs is active delegation, because the RN directs assistive personnel to perform certain tasks and holds the individual accountable. Instructing UAPs to reposition the client is also an active delegation as the UAP is carrying out certain tasks that are directed by the RN. Instructing the UAP to place the oxygen mask is an active delegation because the RN directs assistive personnel to perform certain tasks.

Which approach would the nurse take for a client with Alzheimer disease who is fearful and anxious about being admitted?

Reassuring the client with the presence of same staff members

Which parameter would the nurse assess first when evaluating memory impairment in a client with Alzheimer disease

Remembrance of recent events

Which instruction will the nurse give a client with migraine headaches who is starting triptan medication therapy?

Report any chest discomfort to the health care provider."

A school-age child with a seizure disorder is prescribed divalproex. The nurse would include which instruction when teaching the parents about administering this medication?

Take the child for regularly scheduled blood tests

Which action would the nurse take for an older client with Alzheimer disease who has intermittent episodes of urinary incontinence?

Take the client to the bathroom at regular intervals

A newborn with a cleft lip and palate is born to a mother who has a history of epilepsy. Which medication would the nurse suspect as being responsible for this malformation?

Topiramate

A client is admitted to the hospital with a tonic-clonic seizure after his seizures had been well controlled by phenytoin for 6 months. The client says to the nurse, "I am so upset. I didn't think I was going to have more seizures." Which response would the nurse make?

You are worried about having more seizures

Which beta-adrenergic blocker is prescribed to clients with glaucoma?

betaxolol

Which information would the nurse include in explaining glaucoma to a client?

An increase in the pressure within the eyeball

A child is weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The nurse suspects acute poststreptococcal glomerulonephritis (APSGN). Which question would the nurse ask the mother?

"Did your child have a sore throat during the past 3 weeks?"If the response to the question indicates a recent sore throat, the health care provider may decide to prescribe specific tests to confirm a diagnosis of ASPGN. Weight loss usually occurs in children with type 1 diabetes, not glomerulonephritis. This kind of pain is reported in rheumatic fever and scarlet fever, which do not result in the smoky urine associated with hematuria. A rash on the palms and soles is not associated with APSGN.

A client with glaucoma is receiving a carbonic anhydrase inhibitor. Which statement made by the client will require the nurse to notify the primary health care provider?

"I am allergic to sulfonamides."

A child with cerebral palsy undergoes a tendon-lengthening procedure. The parents ask why their child must wear braces and shoes for at least 12 hours a day, even while in bed. Which is the best response by the nurse?

"They maintain body alignment and help prevent foot drop

Which response would the nurse provide a parent whose infant was diagnosed with cerebral palsy at 6 months of age about why the infant was not diagnosed after birth?

"Until there's control of voluntary movement, a diagnosis can't be confirmed."

A client develops a seizure disorder as a result of a traumatic fall. During a clinic visit, the client states, "I have not had a seizure in 2 years. When can I stop taking my antiseizure medications?" Which response would the nurse provide?

A gradual reduction in seizure medication may be considered.

A client with stage 1 Alzheimer begins to demonstrate aphasia. Which intervention will the nurse use?

Allow extra time for client to verbalize needs and thoughts.

Which explanation would the nurse provide a client who asks what a cataract is?

An opacity of the lens

Apraxia

Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.

Which response would the nurse make to a client's daughter who asks when it would be best to visit her mother who has Alzheimer disease?

Around 2:30 in the afternoon would be a good time to visit

Which intervention would the nurse include in the nursing home plan of care for an older adult with Alzheimer disease who has nighttime wandering?

Assign the client to a room near the nurses' station for closer supervision at night.

Which ophthalmic solution is contraindicated for clients with glaucoma?

Atropine

Which instruction is important for the nurse to provide to the client after cataract surgery?

Avoid bending from the waist

Barbiturates

Barbiturates are used to treat epilepsy and are the most common causative agents of toxic epidermal necrolysis (TEN). Diffuse redness and large blisters on the buccal mucosa are the clinical signs of TEN. Though pyrazolones and sulfonamides also cause TEN, they are not used in treating epilepsy. Benzodiazepines are used in treating epilepsy but do not cause TEN.

Donepezil is prescribed for a client who has mild dementia of the Alzheimer type. Which information would the nurse include when discussing this medication with the client and family?

Blood tests that reflect liver function will be performed routinely

A nurse in the pediatric clinic would be most observant for signs of cerebral palsy in a 6-month-old infant in which instance?

Born at 32 weeks' gestation

client with a diagnosis of dementia of the Alzheimer type has been taking donepezil 10 mg/day for 3 months. The client's partner calls the clinic and reports that the client has increasing restlessness and agitation accompanied by nausea. Which advice would the nurse give the partner?

Bring the partner to the clinic for testing and a physical examination

The nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How would the nurse test cranial nerve XI?

By telling the adolescent to shrug the shoulders

When planning long-term care for a 2-year-old child with cerebral palsy (CP), which is important for the nurse to consider?

CP is not progressively degenerative. CP is a nonprogressive chronic condition and its effects are predictable. Although CI may be present in some children with CP, not all children with this disorder have CI. A variety of prenatal, perinatal, and postnatal factors contribute to the development of CP. It is estimated that the cause of CP is unknown in as many as 80% of people with the disorder.

Which antiseizure medications would the nurse identify as being used to stabilize a client's mood by suppressing mania associated with bipolar disorder (BPD)? Select all that apply. One, some, or all responses may be correct.

Carbamazepin, Divalproex sodium, Lamotrigine

The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia and lives alone, with adult children living nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. Which nursing intervention is correct to assist the client with taking the medication?

Contact the primary health care provider and discuss the possibility of simplifying the medication regimen.

Which information would the nurse include about future treatment and precautions when teaching a client who has glaucoma?

Continuation of therapy for life

During electroconvulsive therapy (ECT), the health care provider administers an electrical shock, and the seizure duration is 60 seconds. Place in priority order the nursing actions that would be taken after the seizure ends.

Ensure an airway is open, check vitals, orient the patient to place and time, assess patient for presence of short term memory loss, provide nourishment because the patient has been on NPO status

Which action would the nurse perform immediately according to priority of care for a client with tonic-clonic seizures?

Ensuring a patent airway.

Which is the most essential instruction for the nurse to give the parents of a child with cerebral palsy who has a slight sensory loss in the lower extremities and wears leg braces?

Examine the skin for evidence of pressure points. When sensory perception is impaired, with resultant lack of effective specific motor responses, the child will be more vulnerable to skin irritation and trauma.

A client is admitted to the hospital after having a tonic-clonic seizure and is diagnosed with a seizure disorder. Which is most important for the nurse to include in a teaching program?

Explain strategies a client may use to prevent physical trauma from occurring during a seizure.

Which factor would cause a rise in temperature to 102°F (38.9°C) after a seizure in a client with eclampsia?

Irregularity in the cerebral thermal center

Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation?

Leave a dim light on in the client's room at night.

For which clinical manifestations would the nurse assess the client diagnosed with Alzheimer disease? Select all that apply. One, some, or all responses may be correct.

Loss of recent memory. Perceptual disturbances. Difficulty learning something new

The nurse anticipates that the family of a child with cerebral palsy (CP) is at risk for difficult parenting issues. Which would the nurse conclude is the probable basis for this difficulty?

Loss of the expected healthy child

Which rationale would the nurse include in teaching a client with glaucoma about the need for treatment?

Lost vision cannot be restored

A registered nurse (RN) must assess the body temperature of a client with a history of epilepsy. Which site for measuring temperature is contraindicated in this client?

Oral cavity

A client has been receiving phenytoin for epilepsy and is newly prescribed haloperidol. The nurse would include which information when teaching the client about the interaction of these medications?

Potentiation of haloperidol's central nervous system depressant effect

A client, who is currently taking digoxin 0.125 mg in the morning and alprazolam 0.5 mg twice a day, is prescribed donepezil 5 mg daily for early dementia of the Alzheimer type. Which instruction would the nurse include when teaching the client's spouse about medication administration?

Prefill a weekly medication box with the medications for the client to self-administer."

Which goal is the nurse trying to achieve by reinforcing to the client that it is important to seek treatment for primary open-angle glaucoma (POAG)?

Prevent blindness

A client with a seizure disorder will begin taking phenytoin. Which instructions will the nurse give to the client?

Provide meticulous oral hygiene."

An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury?

Sacrum

An adolescent girl with a seizure disorder refuses to wear a medical alert bracelet. Which would the nurse tell the girl that may help her wear the bracelet consistently?

Select a bracelet similar to bracelets worn by her peers

A debilitated older client who has glaucoma places great value on independence. What would the nurse encourage the client to do after discharge from the hospital?

Self-administer eye medications using appropriate technique

Which nursing intervention would be helpful in meeting the needs of an older adult with Alzheimer disease?

Simplifying the environment as much as possible by limiting the need for decisions

Which medication would be prescribed to the client diagnosed with migraines if she wishes to continue breast-feeding?

Sumatriptan

A client has primary open-angle glaucoma. Which ophthalmic preparation is indicated to manage this condition?

Timolol maleate

Which education would the nurse provide the parents of an infant with cerebral palsy to support setting care goals?

Unknown extent of the disability requires continual adjustments.The infant is too young for specific long-term plans; care planning should incorporate the plan to continually reevaluate care plans because different needs may manifest as the child grows older. Children with cerebral palsy may or may not have cognitive impairments. Cerebral palsy does not get progressively worse; placement outside the home depends on the child's needs and the parents' abilities and desires. There is no relationship between cerebral palsy and a lowered immune response.

A client has a tonic-clonic seizure at work and is admitted to the emergency department. Which question is most useful when planning nursing care related to the client's seizure?

Were you aware of anything different or unusual just before your seizure began?

The nurse concludes that a client with glaucoma needs education when the client makes which statement?

"Sedatives may increase the pressure in my eye."

A client reports feeling nauseated immediately after cataract surgery. Which action would the nurse take?

Administer the prescribed antiemetic

Which parent education would the nurse provide the parents caring for their infant with cerebral palsy?

Preserve muscle tone to prevent joint contractures. Children with cerebral palsy are especially prone to muscle tone disorders, including spasticity, which can lead to joint contractures

After cataract surgery, a client reports feeling nauseated. How can the nurse prevent vomiting?

Administer the prescribed antiemetic medication

Which client statement indicates that the discharge teaching after a cataract extraction and an intraocular lens implant is effective?

I should call the clinic if my eye begins to hurt.

A 9-year-old child who has cerebral palsy, scoliosis, contractures of elbows and wrists and is also incontinent. Which nursing action will best achieve the goal of skin integrity?

Changing disposable diapers every 2 to 3 hours

Which action would the nurse take if a 6-year-old child who is sitting at a table in the playroom has a tonic-clonic seizure with clenched jaws?

Lowering the child to the floor

A 7-year-old child who is taking medication to prevent seizures has been seizure free for 2 years. The child's parents ask the nurse, "How much longer will my child need to take the medication?" Which answer will the nurse provide?

"This is usually attempted after 2 years, but medications must be gradually decreased."

A client on antidepressant therapy develops hyperthermia, seizures, and a heart rate of 200 beats per minute. Which medication would the nurse suspect is responsible for the condition?

Sertraline

Which parent education would the nurse provide about the preferred carrying position for an infant with cerebral palsy prone to scissoring of the legs

Astride one of her hips. Muscular hypertonicity often causes scissoring of the legs in infants with cerebral palsy, and prolonged periods in such positions may worsen the infant's musculoskeletal health. Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

Which information would the nurse include in postoperative teaching for a client who had cataract surgery? Select all that apply. One, some, or all responses may be correct.

Don't blow your nose, avoid bending from the waist

The nurse understands that which second-generation antidepressant can worsen uncontrolled angle-closure glaucoma?

Duloxetine

Which is the most important need for a newly pregnant client receiving phenytoin for seizures?

Explaining why it is extremely important to take the prescribed folic acid supplements

Which imaging technique is specific for Alzheimer disease?

Magnetic resonance spectroscopy (MRS

A school-age child with a seizure disorder has been on long-term carbamazepine therapy. Which intervention would the nurse incorporate into the plan of care?

Monitoring the child's complete blood cell counts

When making rounds, the nurse observes a client who is experiencing a seizure. Which action would the nurse take?

Move obstacles away from the client

While in the playroom, a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. Which action would the nurse take after moving the child to the floor?

Moving objects away from the child

A child sitting on a chair starts having a tonic-clonic seizure with a clenched jaw. Which would be the initial action by the nurse?

Placing the child on the floor

The nurse teaches a nursing student about cluster headaches. Which statement made by the nursing student indicates a need for further teaching?

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 medication would the nurse expect to be prescribed first to reduce the symptoms of a female client who has severe cramping, pain, backache, and a migraine headache and presents with anxiety and mood swings?

Sertraline. A client with severe cramps, backache, and a migraine with anxiety and mood swings likely has premenstrual syndrome (PMS). Selective serotonin reuptake inhibitors (SSRIs) such as sertraline are effective in relieving the symptoms of severe PMS. Buspirone is useful only to relieve anxiety in the client with PMS. Ibuprofen is used to reduce physiological symptoms. Diuretics such as spironolactone are effective in reducing fluid overload.

Which actions will the nurse take to support cognitive ability in clients who have Alzheimer disease? Select all that apply. One, some, or all responses may be correct.

Support safe independence, limit choices, put pictures, click , calendar

Which activities would the nurse initiate for a client with Alzheimer disease who is admitted to a long-term care facility? Select all that apply. One, some, or all responses may be correct.

Weighing the client once a week. Having specialized rehabilitation equipment available. Establishing a schedule with periods of rest after activities

Which information would the nurse include in the teaching plan for the client who is prescribed sumatriptan for migraine headache?

s contraindicated in people with coronary artery disease

According to priority, in which order would the nurse perform care activities for a client with complete partial seizures?

1. Maintain airway. 2. Record time and duration of seizure. 3. Assess vital signs. 4. Perform neurological checks

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma?

Impairment of peripheral vision

Which intervention(s) will the nurse include in a care plan for a client with Alzheimer disease? Select all that apply. One, some, or all responses may be correct.

Limit choices, toilet every 2 hours, encourage participation in self care

A client experienced a tonic-clonic seizure. Which nursing intervention is the priority during the tonic-clonic stage of the seizure?

Protect the client from injury

The nurse observed seizures in a client who is taking lithium for cycles of mania. Which laboratory parameters may lead to this condition?

3 mEq/L (3 mmol/L) serum lithium levels

amnesia

Amnesia is the term for the impairment of memory, both recent and remote.

Which signs and symptoms are the "four A's" of Alzheimer disease?

Amnesia, apraxia, agnosia, aphasia

An infant exhibits purulent conjunctivitis on the fourth day of life and is brought to the emergency department. Which is the priority nursing action?

Assessing the infant for signs of pneumonia

The client with a seizure disorder receives intravenous (IV) phenytoin. The nurse will monitor closely for which condition?

Cardiac dysrhythmias

Which medication worsens uncontrolled angle-closure glaucoma when used for the treatment of generalized anxiety disorder?

Duloxetine

While assessing the eyes of a client, a health care provider notices there is an obstruction to the outflow of aqueous humor. Which additional finding would be noted to support a diagnosis of glaucoma?

Elevated intraocular pressure

Which factors can trigger a client's migraine attacks? Select all that apply. One, some, or all responses may be correct.

Fatigue, sleep problems, hormonal fluctuations. Fatigue tires the body and causes headaches. Sleep problems may increase the risk for disturbance to the brain. Hormonal fluctuations in different stages can trigger a migraine attack. Vertigo, aphasia, and tingling sensations are the symptoms of migraine headaches, not triggers

To keep the client with Alzheimer disease who has hyperorality safe, which parameter would the nurse have the staff closely monitor?

For attempts at eating inedible objects

Which action would the nurse take for an older resident in a nursing home with Alzheimer disease who hoards leftover food and other seemingly valueless articles and stuffs them into pockets "so the others won't steal them"?

Give the resident a small bag in which to place selected personal articles and food.

After cataract surgery, the nurse teaches a client how to self-administer eyedrops. The nurse would reinforce the use of which technique?

Holding the dropper tip above the conjunctival sac

Which response reported by an older adult client would the nurse identify as consistent with the diagnosis of macular degeneration?

I can't see objects in the center of my vision field.

A client with migraine headaches is scheduled for an electroencephalogram (EEG). Which statement by the client indicates to the nurse that preprocedure teaching has been effective?

I will need to avoid beverages with caffeine. Caffeine products usually are avoided before an EEG because of their effect on brain activity. A headache is not a complication after an EEG. It is not necessary to avoid milk or other calcium-rich foods. Antianxiety and sleep medications usually are discontinued before the EEG because of their effect on brain activity.

Which statement indicates the nurse has a correct understanding about trigeminal autonomic cephalalgia (cluster headaches)?

It is caused by an overactive hypothalamus.Cluster headaches are most commonly seen in men aged 20 to 50 years, and they cause intense unilateral headaches of short duration lasting 30 minutes to 2 hours.

The registered nurse (RN) is delegating tasks to the health care team. Which team member is most suitable for achieving an effective outcome in the care of a client who has been bedridden for long periods with seizures?

Licensed practical nurse

The registered nurse (RN) is caring for a client with epilepsy. Which tasks delegated by the registered nurse (RN) to the members of the health care team indicate active delegation? Select all that apply. One, some, or all responses may be correct.

Passive delegation includes performing the tasks based on the position description, such as physician or pharmacist. The individual functioning in this role performs these tasks through passive delegation. Instructing the LPN to administer diazepam, medication that was already prescribed by the primary health care provider, is passive delegation. Instructing the LVN to administer sedatives that were already prescribed by the primary health care provider is passive delegation. Instructing the LPN to monitor vital signs is active delegation as the RN directs assistive personnel to perform certain tasks and holds the individual accountable. Instructing the UAP to reposition the client is also an active delegation as the UAP is carrying out certain tasks that are directed by the RN. Instructing the UAP to place the oxygen mask is an active delegation as the RN directs assistive personnel to perform certain tasks.

Which technique used by the nurse demonstrates medication safety and effectiveness when assisting an older client to instill prescribed eyedrops for glaucoma? Select all that apply. One, some, or all responses may be correct.

Pressing the inner canthus for 1 to 2 minutes after instillation

Which action would the nurse take when, upon entering a client's room, he or she discovers the client experiencing a seizure on the floor?

Protect the head.

The nurse notes that a child in a crib has a clamped jaw and is having a tonic-clonic seizure. Which is the priority nursing responsibility at this time?

Protecting the child from self-injury

Status epilepticus develops in an adolescent with a seizure disorder who is taking antiseizure medication. Which reason would the nurse identify as the most common reason for the development of status epilepticus?

The prescribed antiseizure medication probably is not taken consistently.

Which is the priority nursing action when a client admitted with preeclampsia has a seizure?

Turning the client's head to the side

The client, who has severe Alzheimer dementia, can no longer recognize familiar objects such as glasses and toothbrush. Which term describes this situation?

agnosia

Which symptom would the nurse expect the client who has primary open-angle glaucoma to report?

decreased peripheral vision

Which ocular symptom would the nurse expect a client with a diagnosis of dry age-related macular degeneration to report?

Loss of central vision

Which intervention would the nurse include in the plan of care for a client with moderate Alzheimer disease?

Maintain a daily routine of living.

Which intervention would the nurse implement for a client with Alzheimer disease who has become agitated and aggressive and is incontinent of urine and feces?

Manage the behavior

Which nursing intervention would the nurse implement for a forgetful, disoriented client who has Alzheimer disease?

Managing the client's unsafe behaviors

A 2-year-old child is admitted to the pediatric unit with a diagnosis of bacterial meningitis. Which is the most important safety measure for the nurse to institute immediately after the child has a seizure?

Placing the child in the side-lying position

Which action would the nurse take for a client who is having a tonic-clonic seizure?

Taking measures to prevent injury

Which safety instruction would the nurse teach a child with diminished sensation in the legs because of cerebral palsy (CP)?

Test the temperature of the water before a bath

The mother of an infant recently prescribed phenobarbital for seizures calls the pediatric clinic and states that the infant is lethargic and sleeps for long periods. Which response by the nurse is most appropriate?

This is a temporary response to the medication; it usually stops after a few weeks."

Which strategy would the nurse include in a plan of care for a client with Alzheimer disease?

Structure the environment for safety.

The nurse teaches a client's family about the administration of donepezil for treatment of dementia of the Alzheimer type. Which side effect identified by the caregiver indicates to the nurse that further teaching is needed?

Constipation

A client reports a severe, sharp, stabbing headache and intense pain in and around the eye that lasts for up to 1 hour. History reveals that the client had similar episodes of headaches previously that lasted for 10 weeks. Which other symptoms may be manifested by the client? Select all that apply. One, some, or all responses may be correct.

Cluster headaches are associated with other symptoms, including rhinorrhea (a runny nose), tearing of eyes (lacrimation), myosis (pupillary constriction), and ptosis (drooping eyelids)