Chronic Neurologic Problems by Lewis
The nurse determines that teaching about management of migraine headaches has been effective when the patient says
... [Show More] which of the following?
a.
"I can take the (Topamax) as soon as a headache starts."
b.
"A glass of wine might help me relax and prevent a headache."
c.
"I will lie down someplace dark and quiet when the headaches begin."
d.
"I should avoid taking aspirin and sumatriptan (Imitrex) at the same time." ANS: C
It is recommended that the patient with a migraine rest in a dark, quiet area. Topiramate (Topamax) is used to prevent migraines and must be taken for several months to determine effectiveness. Aspirin or other nonsteroidal antiinflammatory medications can be taken with the triptans. Alcohol may precipitate migraine headaches.
DIF: Cognitive Level: Apply (application) REF: 1416 | 1419
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
The nurse will assess a 67-year-old patient who is experiencing a cluster headache for
a.
nuchal rigidity.
b.
unilateral ptosis.
c.
projectile vomiting.
d.
throbbing, bilateral facial pain. ANS: B
Unilateral eye edema, tearing, and ptosis are characteristic of cluster headaches. Nuchal rigidity suggests meningeal irritation, such as occurs with meningitis. Although nausea and vomiting may occur with migraine headaches, projectile vomiting is more consistent with increased intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.
DIF: Cognitive Level: Understand (comprehension) REF: 1414
TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action should the nurse take?
a.
Insert an oral airway during the seizure to maintain a patent airway.
b.
Restrain the patient's arms and legs to prevent injury during the seizure.
c.
Time and observe and record the details of the seizure and postictal state.
d.
Avoid touching the patient to prevent further nervous system stimulation. ANS: C
Because the diagnosis and treatment of seizures frequently are based on the description of the seizure, recording the length and details of the seizure is important. Insertion of an oral airway and restraining the patient during the seizure are contraindicated. The nurse may need to move the patient to decrease the risk of injury during the seizure.
DIF: Cognitive Level: Apply (application) REF: 1422
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
A high school teacher who has just been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, "I cannot teach anymore, it will be too upsetting if I have a seizure at work." Which response by the nurse is best?
a.
"You might benefit from some psychologic counseling."
b.
"Epilepsy usually can be well controlled with medications."
c.
"You will want to contact the Epilepsy Foundation for assistance."
d.
"The Department of Vocational Rehabilitation can help with work retraining." ANS: B
The nurse should inform the patient that most patients with seizure disorders are controlled with medication. The other information may be necessary if the seizures persist after treatment with antiseizure medications is implemented.
DIF: Cognitive Level: Apply (application) REF: 1422
TOP: Nursing Process: Implementation MSC: NCLEX: Psychosocial Integrity
A patient has been taking phenytoin (Dilantin) for 2 years. Which action will the nurse take when evaluating for adverse effects of the medication?
a.
Inspect the oral mucosa.
b.
Listen to the lung sounds.
c.
Auscultate the bowel tones.
d.
Check pupil reaction to light. ANS: A
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or pupil reaction to light. [Show Less]