A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this client’s teaching?
“Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.”
“Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.”
“This drug will relieve the pain during the aura phase soon after a headache has started.”
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura?
Visual disturbances
Lethargy
vertigo
A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider?
Prinzmetal’s angina
Bronchial asthma
Diabetes mellitus
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms and legs, followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity?
Tonic-clonic seizure
Atonic seizure
Myoclonic seizure
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?
Turn the client’s head to the side.
Start fluids via a large-bore catheter.
Administer IV push diazepam.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?
Lorazepam (Ativan)
Atenolol (Tenormin)
Phenytoin (Dilantin)
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the client’s understanding. Which statement by the client indicates a correct understanding of the teaching?
“Even when my seizures stop, I will continue to take this drug.”
“I will not drive a motor vehicle while taking this medication.”
“This medication will stop me from getting 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?
“If I am nauseated, I will not take my epilepsy medication.”
“I will tell my doctor about my prescription and over-the-counter medications.”
“While taking my epilepsy medications, I will not drink any alcoholic beverages.”
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
“Do you live in a crowded residence?”
“When was your last tetanus vaccination?”
“Have you had any viral infections recently?”
. After teaching the wife of a client who has Parkinson disease, the nurse assesses the wife’s understanding. Which statement by the client’s wife indicates she correctly understands changes associated with this disease?
“He may have trouble chewing, so I will offer bite-sized portions.”
“This disease is associated with anxiety causing increased perspiration.”
“He should not socialize outside of the house due to uncontrollable drooling.”
. A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this client’s plan of care?
Keep the head of the bed at 30 degrees or greater.
Teach the client pursed-lip breathing techniques.
Ensure a fluid intake of at least 3 liters per day.
A nurse is teaching the daughter of a client who has Alzheimer’s disease. The daughter asks, “Will the medication my mother is taking improve her dementia?” How should the nurse respond?
It will not improve her dementia but can help control emotional responses.”
“It is used to halt the advancement of Alzheimer’s disease but will not cure it.”
“It will allow your mother to live independently for several more years.”
A nurse assesses a client with Alzheimer’s disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
Evaluate the client’s reaction to a change of environment.
Identify the client’s ability to perform self-care activities.
Assess religious and spiritual needs while in the hospital.
A nurse witnesses a client with late-stage Alzheimer’s disease eat breakfast. Afterward the client states, “I am hungry and want breakfast.” How should the nurse respond?
“I see you are still hungry. I will get you some toast.”
“You ate your breakfast 30 minutes ago.”
“It appears you are confused this morning.”
A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?
Kidney function tests
Serum electrolyte levels
Complete blood cell count
A nurse cares for a client with advanced Alzheimer’s disease. The client’s caregiver states, “She is always wandering off. What can I do to manage this restless behavior?” How should the nurse respond?
“Engage the client in scheduled activities throughout the day.”
“This is a sign of fatigue. The client would benefit from a daily nap.”
It sounds like this is difficult for you. I will consult the social worker.”
A nurse prepares to discharge a client with Alzheimer’s disease. Which statement should the nurse include in the discharge teaching for this client’s caregiver?
Install deadbolt locks on all outside doors.”
“Place a padded throw rug at the bedside.”
“Allow the client to rest most of the day.”
A nurse assesses a client with Huntington disease. Which motor changes should the nurse monitor for in this client?
Jerky hand movements
Shuffling gait
Continuous chewing motions
A nurse cares for a client who has been diagnosed with the Huntington gene but has no symptoms. The client asks for options related to family planning. What is the nurse’s best response?
“Tell me more specifically what information you need about family planning so that I can direct you to the right information or health care provider.”
“The need for family planning is limited because one of the hallmarks of Huntington disease is infertility.”
“I understand that they can diagnose this disease in embryos. Therefore, you could select a healthy embryo from your fertilized eggs for implantation to avoid passing on Huntington disease.”
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this client’s teaching?
“Lie down in a darkened room when you experience a headache.”
“Wear dark sunglasses when you are in brightly lit spaces.”
“Place a warm compress on your forehead at the onset of the headache.”
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client’s care?
“Allow the client to be as independent as possible with activities.”
“Assist the client with frequent and meticulous oral care.”
“Assess the client’s ability to eat and swallow before each meal.”
A nurse delegates care for a client with early-stage Alzheimer’s disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this client’s care?
“Reorient the client to the day, time, and environment with each contact.”
“Remove the clock from her room so that she doesn’t get confused.”
“If she is confused, play along and pretend that everything is okay.”
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client’s plan of care? (Select all that apply.)
Have suction equipment at the bedside.
Keep bed rails up at all times.
Ensure that the client has IV access.
Place a padded tongue blade at the bedside.
Permit only clear oral fluids.
Maintain the client on strict bedrest.
A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this client’s plan of care? (Select all that apply.)
“Incorporate physical exercise into your daily routine.”
“Participate in a smoking cessation program.”
“Increase your intake of fruits and vegetables.”
“Increase your intake of caffeinated beverages.”
“Avoid all alcoholic beverages.”
A nurse evaluates the results of diagnostic tests on a client’s cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.)
Clear
Increased protein level
Normal glucose level
Cloudy
Bacterial organisms present
Increased white blood cells
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.)
Ipsilateral tearing of the eye
Miosis
Nasal congestion
Abrupt loss of consciousness
Neck and shoulder tenderness
Exophthalmos
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.)
Lip smacking
Picking at clothing
Patting of the hand on the leg
Intermittent rigidity
Sudden loss of muscle tone
Brief jerking of the extremities
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.)
Surgical mask
Gloves
Particulate respirator
Isolation gown
Shoe covers
A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.)
A 26-year-old woman with a left temporal brain tumor
A 38-year-old male client in an alcohol withdrawal program
. A 42-year-old football player with a traumatic brain injury
A 66-year-old female client with multiple sclerosis
A 72-year-old man with chronic obstructive pulmonary disease
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.)
Hoarseness
Dysphagia
Seizures
Bleeding
Infection
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
. Sodium level
Clotting factors
Liver enzymes
Cardiac enzymes
Creatinine level
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.)
Dilated pupils
Widened pulse pressure
Bradycardia
Photophobia
Headache
