1. What is the priority nursing diagnosis for a patient experiencing a migraine headache?
a. Acute pain related to biologic and chemical factors
b.
... [Show More] Anxiety related to change in or threat to health status
c. Hopelessness related to deteriorating physiological condition
d. Risk for Side effects related to medical therapy
1. Answer: A – The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management. All of the other nursing diagnoses are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization
2. You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? (Choose all that apply).
a. Avoid foods that contain tyramine, such as alcohol and aged cheese.
b. Avoid drugs such as Tagamet, nitroglycerin and Nifedipine.
c. Abortive therapy is aimed at eliminating the pain during the aura.
d. A potential side effect of medications is rebound headache.
e. Complementary therapies such as relaxation may be helpful.
f. Continue taking estrogen as prescribed by your physician.
2. Answer: S A, B, C, D & E – Medications such as estrogen supplements may actually trigger a migraine headache attack. All of the other statements are accurate. Focus: Prioritization
3. The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
a. Document the seizure.
b. Perform neurologic checks.
c. Take the patient’s vital signs.
d. Restrain the patient for protection.
3. Answer: C – Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision
4. You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?
a. Complete admission assessment.
b. Set up oxygen and suction equipment.
c. Place a padded tongue blade at bedside.
d. Pad the side rails before patient arrives.
4. Answer: B – The LPN/LVN can set up the equipment for oxygen and suctioning. The RN should perform the complete initial assessment. Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family. Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins. Focus: Delegation/supervision.
5. A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene?
a. “You should avoid consumption of all forms of alcohol.”
b. “Wear you medical alert bracelet at all times.”
c. “Protect your loved one’s airway during a seizure.”
d. “It’s OK to take over-the-counter medications.”
. Answer: D – A patient with a seizure disorder should not take over-the-counter medications without consulting with the physician first. The other three statements are appropriate teaching points for patients with seizures disorders and their families. Focus: Delegation/supervision
6. A patient with Parkinson’s disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?
a. The NA assists the patient to ambulate to the bathroom and back to bed.
b. The NA reminds the patient not to look at his feet when he is walking.
c. The NA performs the patient’s complete bath and oral care.
d. The NA sets up the patient’s tray and encourages patient to feed himself.
6. Answer: C – The nursing assistant should assist the patient with morning care as needed, but the goal is to keep this patient as independent and mobile as possible. Assisting the patient to ambulate, reminding the patient not to look at his feet (to prevent falls), and encouraging the patient to feed himself are all appropriate to goal of maintaining independence. Focus: Delegation/supervision
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