The nurse is taking the health history of a patient being treated for Emphysema and Chronic Bronchitis. After being told the patient has been smoking
... [Show More] cigarettes for 30 years, the nurse expects to note which assessment finding?
1. Increase in Forced Vital Capacity (FVC)
2. A narrowed chest cavity
3. Clubbed fingers
4. An increased risk of cardiac failure
1. Increase in Forced Vital Capacity (FVC)
Forced Vital Capacity is the volume of air exhaled from full inhalation to full exhalation. A patient with COPD would have a decrease in FVC. Incorrect.
2. A narrowed chest cavity
A patient with COPD often presents with a 'barrel chest,' which is seen as a widened chest cavity. Incorrect.
3. Clubbed fingers - CORRECT
Clubbed fingers are a sign of a long-term, or chronic, decrease in oxygen levels.
4. An increased risk of cardiac failure
Although a patient with these conditions would indeed be at an increased risk for cardiac failure, this is a potential complication and not an assessment finding. Incorrect.
The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?
1. Melena
2. Nausea
3. Hernia
4. Hyperthermia
1. Melena - CORRECT
Melena is the finding that there are traces of blood in the stool which presents as black, tarry feces. This is a common manifestation of Duodenal Ulcers, since the Duodenum is further down the gastric anatomy.
2. Nausea
Nausea may be present, but is a generalized symptom and by itself doesn't indicate a Duodenal Ulcer. Incorrect.
3. Hernia
A Hernia is a protrusion of a segment of the abdomen through another abdominal structure. It is not associated with an Ulcer and is a condition, not an assessment finding. Incorrect.
4. Hyperthermia
Hyperthermia, a high temperature, is not an assessment finding of a Duodenal Ulcer. Incorrect
A nurse is providing discharge teaching for a patient with severe Gastroesophogeal Reflux Disease. Which of these statements by the patient indicates a need for more teaching?
1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep"
3. "I won't be drinking tea or coffee or eating chocolate any more."
4. "I'm going to start trying to lose some weight."
1. "I'm going to limit my meals to 2-3 per day to reduce acid secretion."
CORRECT - Large meals increase the volume and pressure in the stomach and delay gastric emptying. It's recommended instead to eat 4-6 small meals a day.
2. "I'm going to make sure to remain upright after meals and elevate my head when I sleep"
Incorrect - This is a correct verbalization of health promotion for GERD.
3. "I won't be drinking tea or coffee or eating chocolate any more."
Incorrect - This is a correct verbalization of health promotion for GERD.
4. "I'm going to start trying to lose some weight."
Incorrect - This is a correct verbalization of health promotion for GERD.
The nurse in the Emergency Room is treating a patient suspected to have a Peptic Ulcer. On assessing lab results, the nurse finds that the patient's blood pressure is 95/60, pulse is 110 beats per minute, and the patient reports epigastric pain. What is the PRIORITY intervention?
1. Start a large-bore IV in the patient's arm
2. Ask the patient for a stool sample
3. Prepare to insert an NG Tube
4. Administer intramuscular morphine sulphate as ordered
1. Start a large-bore IV in the patient's arm
CORRECT - The nurse should suspect that the patient is haemorrhaging and will need need a fluid replacement therapy, which requires a large bore IV.
2. Ask the patient for a stool sample
Incorrect - While this is useful in the diagnosis and assessment of Peptic Ulcer Disease, it is not the priority intervention.
3. Prepare to insert an NG Tube
Incorrect - While this intervention may be used in the later stages of Peptic Ulcer Disease, it is not the first and priority intervention.
4. Administer intramuscular morphine sulphate as ordered
Incorrect - While this is an important intervention to manage pain, it is not the priority intervention.
A female patient with atrial fibrillation has the following lab results: Hemoglobin of 11 g/dl, a platelet count of 150,000, an INR of 2.5, and potassium of 2.7 mEq/L. Which result is critical and should be reported to the physician immediately?
1. Hemoglobin 11 g/dl
2. Platelet of 150,000
3. INR of 2.5
4. Potassium of 2.7 mEq/L
1. Hemoglobin 11 g/dl
This is below normal, but a normal female hemoglobin is 12-14. There is a more critical lab result.
2. Platelet of 150,000
This is also below the normal values, but is not the most critical lab result.
3. INR of 2.5
This is a therapeutic range for a patient who is taking an anticoagulant for atrial fibrillation
4. Potassium of 2.7 mEq/L
CORRECT - A potassium imbalance for a patient with a history of dysrhythmia can be life-threatening and can lead to cardiac distress.
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
1. Stop the saline infusion immediately
2. Notify Physician
3. Elevate the patient's legs
4. Continue the infusion, since these are normal findings
1. Stop the saline infusion immediately
CORRECT - the patient has a fluid volume overload as a result of overly rapid fluid replacement. The nurse should stop the infusion and notify the physician.
2. Notify Physician
This is not the first action the nurse should take.
3. Elevate the patient's legs
This would help with the edema, but is not a priority
4. Continue the infusion, since these are normal findings
This is not a normal finding
The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?
1. They must inform household members of their condition
2. They must take their medications exactly as prescribed
3. They must abstain from substance use
4. They must avoid large crowds
1. They must inform household members of their condition
Incorrect - Each patient has a right to privacy of their medical condition. It is their choice whether they inform household members.
2. They must take their medications exactly as prescribed
CORRECT - Antiretrovirals must be taken exactly as prescribed to prevent drug-resistant strains. Even missed doses can reduce the effectiveness of future treatment.
3. They must abstain from substance use
Incorrect - While substance use should be discouraged, using safe practices with needles can prevent transmission of HIV.
4. They must avoid large crowds
Incorrect - Avoiding large crowds to prevent infection is a priority in the later stages of HIV, when the patient has AIDS.
A nurse finds a 30-year-old woman experiencing anaphylaxis from a bee sting. Emergency personnel have been called. The nurse notes the woman is breathing but short of breath. Which of the following interventions should the nurse do first?
1. Initiate cardiopulmonary resuscitation
2. Check for a pulse
3. Ask the woman if she carries an emergency medical kit
4. Stay with the woman until help comes
1. Initiate cardiopulmonary resuscitation
Incorrect - CPR is premature at this point, and there is another action that can be taken first.
2. Check for a pulse
This is the first step when assessing for initiation of CPR, but CPR is not the best and first course of action for this situation. The woman is still breathing, which means CPR is not necessary at this time.
3. Ask the woman if she carries an emergency medical kit
CORRECT - Many patients who have a known history of anaphylaxis carry epi-pens in their pockets or belongings. This is the best way to stop a hypersensitivity reaction before it becomes life-threatening.
3. Stay with the woman until help comes
Incorrect - While this should be done, it's not the best and first course of action.
A man is prescribed lithium to treat bipolar disorder. The nurse is most concerned about lithium toxicity when he notices which of these assessment findings?
1. The patient states he had a manic episode a week ago
2. The patient states he has been having diarrhea every day
3. The patient has a rashy pruritis on his arms and legs
4. The patient presents as severely depressed
5. The patient's lithium level is 1.3 mcg/L
1. The patient states he had a manic episode a week ago
Incorrect - Having a manic episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level.
2. The patient states he has been having diarrhea every day
Correct - Persistent diarrhea can lead to dehydration, which can increase the risk of lithium toxicity.
3. The patient has a rashy pruritis on his arms and legs
Incorrect - This is not a symptom of lithium toxicity
4. The patient presents as severely depressed
Incorrect - Having a depressive episode is not an indication of lithium toxicity. This finding indicates that the lithium is not effective or is not at a therapeutic level.
5. The patient's lithium level is 1.3 mcg/L
This is within the therapeutic range of lithium
A 65 year old man is prescribed Flomax (Tamsulosin) for Benign Prostatic Hyperplasia. The patient lives in an upstairs apartment. The nurse is most concerned about which side effect of Flomax?
1. Hypotension
2. Tachycardia
3. Back Pain
4. Difficulty Urinating
1. Hypotension
Correct - Hypotension can lead to dizziness and a risk for injury to the patient.
2. Tachycardia
Tachycardia can be a side effect of Flomax, but is not an immediate safety risk, nor is it a common side effect.
3. Back Pain
Back Pain can be a side effect of Floma, but is not a safety risk
4. Difficulty Urinating
Dysuria is a symptom of Benign Prostatic Hyperplasia, not a side effect of Flomax
A man is receiving heparin subcutaneously. The patient has dementia and lives at home with a part-time caretaker. The nurse is most concerned about which side effect of heparin?
1. Back Pain
2. Fever and Chills
3. Risk for Bleeding
4. Dizziness
1. Back Pain
Incorrect - Back pain, while it can occur, is not an immediate concern
2. Fever and Chills
Incorrect - Fever and Chills, while it can occur, is not an immediate concern
3. Risk for Bleeding
Correct - A confused patient is at risk for injuring themselves and at risk for hemorrhage should an injury occur
4. Dizziness
Incorrect - Dizziness is not a side effect of Heparin
A female patient is prescribed metformin for glucose control. The patient is on NPO status pending a diagnostic test. The nurse is most concerned about which side effect of metformin?
1. Diarrhea and Vomiting
2. Dizziness and Drowsiness
3. Metallic taste
4. Hypoglycemia
1. Diarrhea and Vomiting
Incorrect - While these may occur, the patient is at higher risk for another adverse effect.
2. Dizziness and Drowsiness
Incorrect - While these may occur, the patient is at higher risk for another adverse effect.
3. Metallic taste
Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
4. Hypoglycemia
Correct - The patient is at risk because she is on NPO status and continuing to take an anti-glycemic drug.
The nurse is reviewing the lab results of a patient taking lithium for schizoaffective disorder. The lab results show that the blood lithium value is 1.7 mcg/L. What would the nurse take as the priority action?
1. Induce vomiting
2. Hold the next dose of Lithium
3. Administer an anti-emetic
4. Give the next dose of Lithium
1. Induce vomiting
Incorrect - This may be warranted for a severe lithium toxicity, but would be premature at this point. Gastric lavage may be attempted if the patient presents within one hour of ingestion, and fluids will be given to restore kidney function and promote the clearance of Lithium from the body..
2. Hold the next dose of Lithium
Correct - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
3. Administer an anti-emetic
Incorrect - While minor toxicity can cause vomiting and nausea, this is not a priority action
4. Give the next dose of Lithium
Incorrect - Lithium's therapeutic range is 0.5-1.5mcg/L, and begins toxicity at 1.5mcg/L
A patient asks the nurse why they must have a heparin injection. What is the nurse's best response?
1. "Heparin will dissolve clots that you have."
2. "Heparin will reduce the platelets that make your blood clot"
3. "Heparin will work better than warfarin."
4. "Heparin will prevent new clots from developing."
1. "Heparin will dissolve clots that you have."
Incorrect - Heparin does not do this.
2. "Heparin will reduce the platelets that make your blood clot"
Incorrect - Heparin does not do this
3. "Heparin will work better than warfarin."
Incorrect - Heparin has a different mechanism of action than warfarin, and a different route of administration, but achieve similar results.
4. "Heparin will prevent new clots from developing."
Correct -This is a correct statement.
The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the troponin T value is at 5.3 ng/mL. Which of these interventions, if not completed already, would take priority over the others?
1. Put the patient in a 90 degree position
2. Check whether the patient is taking diuretics
3. Obtain and attach defibrillator leads
4. Check the patient's last ejection fraction
1. Put the patient in a 90 degree position
Incorrect - This position is optimal for helping a patient breathe, but is not the priority action in an emergency situation.
2. Check whether the patient is taking diuretics
Incorrect - Diuretics play a role in CHF by decreasing fluid volume, but this patient is likely having an acute myocardial infarction.
3. Obtain and attach defibrillator leads
Correct - This patient is undergoing an emergency cardiac event. Normal Troponin T levels are less than 0.2 ng/mL. Ventricular Fibrillation is the cause of death in most cases of deaths due to sudden cardiac arrest. Defibrillation is the most important action to take to prevent death.
4. Check the patient's last ejection fraction
Incorrect - Ejection fraction is a test used to gauge the severity of CHF, not an emergency cardiac arrest.
A nurse is caring for a patient undergoing a stress test on a treadmill. The patient turns to talk to the nurse. Which of these statements would require the most immediate intervention?
1. "I'm feeling extremely thirsty. I'm going to get some water after this."
2. "I can feel my heart racing."
3. "My shoulder and arm is hurting."
4. "My blood pressure reading is 158/80"
1. "I'm feeling extremely thirsty. I'm going to get some water after this."
Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.
2. "I can feel my heart racing."
Incorrect - This does not require immediate intervention. This is a common response to exercise and activity.
3. "My shoulder and arm is hurting."
Correct - Unilateral arm and shoulder pain is one of the classic symptoms of myocardial ischemia. The stress test should be halted.
4. "My blood pressure reading is 158/80"
Incorrect - This does not require immediate intervention. Moderate elevation in blood pressure is a common response to exercise and activity.
The nurse is reviewing the lab results of a patient who has presented in the Emergency Room. The lab results show that the BNP (B-type Natriuretic Peptide) value is a 615 pg/ml. What would the nurse take as the priority action?
1. Call a cardiac code and implement emergency measures
2. Check the patient's oxygen saturation
3. Inform the physician that the patient has Congestive Heart Failure
Encourage the patient to limit activity
1. Call a cardiac code and implement emergency measures
Incorrect - There is no evidence that the patient is undergoing a cardiac arrest.
2. Check the patient's oxygen saturation
Correct - An elevated BNP indicates that there is decreased cardiac output. A priority intervention would be to ensure proper oxygenation after an assessment.
3. Inform the physician that the patient has Congestive Heart Failure
Incorrect - Although BNP suggests Congestive Heart Failure, it is not used in itself to diagnose CHF. An elevated BNP can also be caused by dysrhythmias or renal disease.
4. Encourage the patient to limit activity
Incorrect - This is an intervention that can help treat CHF, but not a priority action at this time.
A nurse is caring for a patient after a coronary angiogram. Which of these actions taken by the nursing assistant would most require the nurse's immediate intervention?
1. The nursing assistant fills the patient's pitcher with ice cold drinking water
2. The nursing assistant elevates the head of the bed to 60 degrees for a meal
3. The nursing assistant refills the ice pack laying on the insertion site
4. The nursing assistant places an extra pillow under the patient's head on request
1. The nursing assistant fills the patient's pitcher with ice cold drinking water
Incorrect - It is recommended to generously hydrate after a coronary angiogram to excrete contrast medium, reducing kidney toxicity
2. The nursing assistant elevates the head of the bed to 60 degrees for a meal
Correct - For 3-6 hours after a coronary angiogram (depending on the insertion site), the patient should have their bed no higher than 30 degrees and be on bedrest.
3. The nursing assistant refills the ice pack laying on the insertion site
Incorrect - An ice pack or dressing is recommended to be placed on the insertion site to minimize risk of bleeding.
4. The nursing assistant places an extra pillow under the patient's head on request
Incorrect - An extra pillow will not violate any post-procedural protocols for coronary angiogram.
A man is has been taking lisinopril for CHF. The patient is seen in the emergency room for persistent diarrhea. The nurse is concerned about which side effect of lisinopril?
1. Vertigo
2. Hypotension
3. Palpitations
4. Nagging, dry cough
1. Vertigo
Incorrect - While this may occur, the patient is at higher risk due to another adverse effect.
2. Hypotension
Correct - The patient is particularly at risk for hypotension due to possible dehydration from fluid loss.
3. Palpitations
Incorrect - While this may occur, the patient is at higher risk for another adverse effect.
4. Nagging, dry cough
Incorrect - While this is a common side effect, the patient is at higher risk for another adverse effect..
The nurse is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the nurse expects to note which assessment finding?
1. Severe and persistent diarrhea
2. Intense pain in the toe
3. Yellow-tinged sclera
4. Headache
1. Severe and persistent diarrhea
Incorrect - This is not a manifestation of sickle cell disease
2. Intense pain in the toe
Incorrect - Gout is a manifestation of Polycythemia Vera, in which the there is an overabundance of red blood cells
3. Yellow-tinged sclera
Correct - Jaundice is a common clinical finding of sickle cell disease, caused by bilirubin released from damaged or destroyed RBCs
4. Headache
Incorrect - While this may occur, it is not indicative or a classic symptom of sickle cell disease.
A client with Multiple Sclerosis reports a constant, burning, tingling pain in the shoulders. The nurse anticipates that the physician will order which medication for this type of pain?
1. alprazolam (Xanax)
2. Corticosteroid injection
3. gabapentin (Neurontin)
4. hydrocodone/acetaminophen (Norco)
1. alprazolam (Xanax)
Incorrect - alprazolam is used to reduce anxiety
2. Corticosteroid injection
Incorrect - Corticosteroid injections are used to reduce inflammation in a localized area, often due to joint breakdown. In MS patients it is used to treat acute exacerbations ("flare-ups"), but the symptoms described do not constitute an acute exacerbation.
3. gabapentin (Neurontin)
Correct - Anticonvulsants like gabapentin are often the first line of treatment for nerve pain
4. hydrocodone/acetaminophen (Norco)
Incorrect - Opioids would not be the appropriate medication to treat nerve pain.
Which of these clients is likely to receive sublingual morphine?
1. A 75-year-old woman in a hospice program
2. A 40-year-old man who just had throat surgery
3. A 20-year-old woman with trigeminal neuralgia
4. A 60-year-old man who has a painful incision
1. A 75-year-old woman in a hospice program
Correct - Sublingual morphine is often used in hospice because the patients are unable to swallow, and intravenous access can be painful and not conducive to palliative care.
2. A 40-year-old man who just had throat surgery
Incorrect - Patients who have surgery most likely have an Intravenous line
3. A 20-year-old woman with trigeminal neuralgia
Incorrect - Morphine would not be the first choice for nerve pain
4. A 60-year-old man who has a painful incision
Incorrect - Although Morphine would be an appropriate medications, there is no indication that it should be administered sublingually
In educating clients on ways to manage pain, which topic can be appropriately delegated to a LPN/LVN who will continue under supervision?
1. Acupuncture
2. Guided Imagery
3. Alternating Rest/Activity
4. Over the counter medications
1. Acupuncture
Incorrect - This is outside the nursing scope of practice and requires special training or education
2. Guided Imagery
Incorrect - This also requires additional training or education
3. Alternating Rest/Activity
Correct - This is within the nursing scope of practice and within the training and education provided to all nurses. It is safe to use and a standard treatment.
4. Over the counter medications
Incorrect - This is outside the nursing scope of practice. A healthcare provider (doctor, nurse practitioner, or physician's assistant) should be consulted before taking over the counter medications.
The nurse assesses a patient suspected of having an asthma attack. Which of the following is a common clinical manifestation of this condition?
1. Audible crackles and orthopnea
2. An audible wheeze and use of accessory muscles
3. Audible crackles and use of accessory muscles
4. Audible wheeze and orthopnea
1. Audible crackles and orthopnea
Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma. Orthopnea is not associated with asthma.
2. An audible wheeze and use of accessory muscles
Correct - Both of these are associated with asthma.
3. Audible crackles and use of accessory muscles
Incorrect - Crackles indicate fluid in the lungs, which is not a cause of asthma.
4. Audible wheeze and orthopnea
Incorrect - Orthopnea is not associated with asthma.
The nurse assesses a patient suspected of having meningitis. Which of the following is a common clinical manifestation of this condition?
1. A high WBC count and decreased level of consciousness
2. A high WBC count and manic activity
3. A low WBC count and manic activity
4. A low WBC count and decreased level of consciousness
1. A high WBC count and decreased level of consciousness
Correct - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
2. A high WBC count and manic activity
Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
3. A low WBC count and manic activity
Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
4. A low WBC count and decreased level of consciousness
Incorrect - Meningitis is most often cause by an infectious organism, increasing the WBC count. One defining feature is an increased Intracranial Pressure (ICP) which presents as a decreased level of consciousness.
A patient is being treated in the Neurology Unit for Meningitis. Which of these is a priority assessment for the nurse to make?
1. Assess the patient for nuchal rigidity
2. Determine the patient's past exposure to infectious organisms
3. Check the patient's WBC lab values
4. Monitor for increased lethargy and drowsiness
1. Assess the patient for nuchal rigidity
Incorrect - Although neck stiffness can be a symptom of Meningitis, it is not used to define meningitis, neither is it a sign of further neurological deterioration.
2. Determine the patient's past exposure to infectious organisms
Incorrect - Although this is an important part of the history gathering process, and meningitis is most often caused by a viral or bacterial infection, it is not the priority assessment.
3. Check the patient's WBC lab values
Incorrect - Although WBCs do rise during an infection like Mengingitis, it is not the priority assessment.
4. Monitor for increased lethargy and drowsiness
Correct - Lethargy and drowsiness indicate a decreased level of consciousness, which is the cardinal sign of increased ICP (Intracranial Pressure), which can be life-threatening.
The nurse is caring for clients in the pediatric unit. A 6-year patient is admitted who has 2nd and 3rd degree burns on his arms. The nurse should assign the new patient to which of the following roommates?
1. A 4-year old with sickle-cell disease
2. A 12-year old with chickenpox
3. A 6-year old undergoing chemotherapy
4. A 7-year old with a high temperature
1. A 4-year old with sickle-cell disease
Correct - The nurse should be concerned about the burn patient's vulnerability to infection. Sickle cell disease is not a communicable disease.
2. A 12-year old with chickenpox
Incorrect - Chickenpox is a communicable disease
3. A 6-year old undergoing chemotherapy
Incorrect - This patient is already immunosuppressed and should not have a roommate regardless.
4. A 7-year old with a high temperature
Incorrect - An unspecified fever is often indicative of an infection of some type.
A patient with Meningitis is being treated with Vancomycin intravenously 3 times per day. The nurse notes that the urine output during the last 8 hours was 200mL. What is the nurse's priority action?
1. Check the patient's last BUN
2. Ask the patient to increase their fluid intake
3. Ask the physician to order a diuretic
4. Notify the physician of this finding
1. Check the patient's last BUN
Incorrect - This may be relevant to nephrotoxicity and poor urine output, but is not the priority action. An assessment finding has already been done and indicates an immediate intervention.
2. Ask the patient to increase their fluid intake
Incorrect - Increasing oral intake without other interventions will increase risk of increased ICP and fluid overload.
3. Ask the physician to order a diuretic
Incorrect - This is premature and would not be the correct intervention.
4. Notify the physician of this finding
Correct - Vancomycin is a nephrotoxic drug and can cause impaired renal perfusion, which would cause a decreased urine output. This is a serious adverse effect and should be reported to the physician.
A patient is being admitted to the ICU with a severe case of encephalitis. Which of these drugs would the nurse not be expect to be prescribed for this condition?
1. Acyclovir (Zovirax)
2. Mannitol (Osmitrol)
3. Lactated Ringer's
4. Phenytoin (Dilantin)
1. Acyclovir (Zovirax)
Incorrect- Acyclovir is a common antiviral drug for the treatment of viral encephalitis
2. Mannitol (Osmitrol)
Incorrect - Mannitol is a hyperosmolar drug that helps reduce Intracranial Pressure by acting as a diuretic and decreasing fluid in the body.
3. Lactated Ringer's
Correct - Lactated Ringer's solution is often used in fluid replacement therapy, which is not warranted if a patient is at risk for high ICP.
4. Phenytoin (Dilantin)
Incorrect - Phenytoin is an anticonvulsant and is often used to prevent seizures, which can complicate and worsen a patient's neurological state.
The nurse is treating a patient who has Parkinson's Disease. Which of these practices would not be included in the care plan?
1. Decrease the calorie content of daily meals to avoid weight gain
2. Allow the patient extra time to respond to questions and do ADLs
3. Use thickened liquids and a soft diet
4. Encourage the patient to hold the spoon when eating
1. Decrease the calorie content of daily meals to avoid weight gain
Correct - Calorie content should be increased for patients with Parkinson's Disease because of dysphagia (difficulty swallowing), as well as calories burned due to muscle rigidity.
2. Allow the patient extra time to respond to questions and do ADLs
Incorrect - This is a best practice when working with PD patients.
3. Use thickened liquids and a soft diet
Incorrect - This is often used to reduce the risk of aspiration
4. Encourage the patient to hold the spoon when eating
Incorrect - The patient should be encouraged to perform ADLs as independently as possible.
A 45-year old woman is prescribed ropinirole (Requip) for Parkinson's Disease. The patient is living at home with her daughter. The nurse is most concerned about which side effect of ropinirole?
1. Slurred speech
2. Sudden dizziness
3. Masklike facial expression
4. Stooped Posture
1. Slurred speech
Incorrect - Slurred speech is a common symptom of PD, not a side effect of this drug.
2. Sudden dizziness
Correct - Dizziness and orthostatic hypotension are serious adverse effects of this drug that can lead to an increased risk of falls. Ropinirole's drug class is a dopamine agonist, which mimic dopamine in the brain (PD is characterized by a lack of dopamine).
3. Masklike facial expression
Incorrect - Masklike facial expression is a common symptom of PD, not a side effect of this drug.
4. Stooped Posture
Incorrect - Stooped Posture is a common symptom of PD, not a side effect of this drug.
The nurse is taking the health history of a patient being treated for Parkinson's Disease. After being told the patient has classic symptoms of Parkinson's, the nurse expects to note which assessment finding?
1. Tremors
2. Low Urine Output
3. Exaggerated arm movements
4. Risk for Falls
1. Tremors
Correct - Tremors is one of four cardinal signs of PD: the other three are rigidity, bradykinesia (slow movements), and postural instability
2. Low Urine Output
Incorrect - This is not a relevant symptom to PD
3. Exaggerated arm movements
Incorrect - A symptom of PD would be rigidity and slow arm movements, rather than exaggeration of arm movements
4. Risk for Falls
Incorrect - This is not an assessment finding. This is a nursing diagnosis.
A nurse enters a patient's room and finds them unconscious with a rhythmic jerking of all four extremities. The patient is foaming heavily at the mouth. The patient was on seizure precautions and the bedrails are up and padded. What is the nurse's priority action?
1. Administer Lorazepam (Ativan)
2. Turn the patient to his/her side
3. Call the physician
4. Suction the patient
1. Administer Lorazepam (Ativan)
Incorrect - If a seizure lasts more than 5 minutes, it is called Status epilepticus and can be life-threatening. Physicians will often order anxiolytics or sedatives to treat this condition. However, at this point it would not be appropriate for the nurse to administer this drug.
2. Turn the patient to his/her side
Correct - Turning the patient to the side will keep the airway open, which is the first priority
3. Call the physician
Incorrect - This would be a priority action after ensuring the patient's safety, or in the case of Status epilepticus
4. Suction the patient
Incorrect - This intervention is warranted, but after an assessment of the patient's airway, since forcing a suction catheter into a patient's mouth is a last resort.
A nurse is giving a discharge education to a patient who has been diagnosed with epilepsy. Which of these teachings would she stress the most?
1. Avoid doing alcohol and drugs
2. Follow up with the neurologist, physician, or other health care provider as prescribed
3. Do not stop taking anticonvulsants, even if seizures have stopped
4. Wear a medical alert bracelet or carry an ID card indicating epilepsy
1. Avoid doing alcohol and drugs
Incorrect - Although this is a general teaching that would be applied to any hospital discharge situation, it is not the priority to be stressed.
2. Follow up with the neurologist, physician, or other health care provider as prescribed
Incorrect - Although this is correct to include in discharge education, following this instruction is not directly contributing to their safety, so is not the priority.
3. Do not stop taking anticonvulsants, even if seizures have stopped
Correct - Following this instruction is essential for their safety, since stopping anti-epileptic drugs suddenly can cause seizures and an increased chance of status epilecticus
4. Wear a medical alert bracelet or carry an ID card indicating epilepsy
Incorrect - Although this is correct to include in discharge education, following this instruction is not directly contributing to their safety, so is not the priority.
The nurse is caring for a patient in the ICU who has had a spinal cord injury. She observes that his last blood pressure was 100/55, and his pulse is 48. These have both trended downwards from the baseline. What should the nurse expect to be the next course of action ordered by the physician?
1. Assess the patient for decreased level of consciousness
2. Administer Normal Saline
3. Insert an NG Tube
4. Connect and read an EKG
1. Assess the patient for decreased level of consciousness
Incorrect - An assessment has already been made, and an intervention is warranted.
2. Administer Normal Saline
Correct - The patient is entering neurogenic shock. Normal saline will replace fluid volume, treating the hypotension and bradycardia symptomatically. Atropine sulfate is also commonly used to increase the heart rate.
3. Insert an NG Tube
Incorrect - An NG tube would not be relevant in this situation.
4. Connect and read an EKG
Incorrect - An EKG would not be needed in this situation. [Show Less]