Ch. 42 Flashcards
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?
a.
“Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache.”
b.
“Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.”
c.
“This drug will relieve the pain during the aura phase soon after a headache has started.”
d.
“This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.”
ANS: B
Beta blockers are prescribed as prophylactic treatment to prevent the vascular changes that initiate migraine headaches. Heart rate and blood pressure will also be affected, and the client should monitor these side effects. The other responses do not discuss appropriate uses of the medication.
DIF: Applying/Application REF: 856
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?
a.
Vertigo
b.
Lethargy
c.
Visual disturbances
d.
Numbness of the tongue
ANS: C
Early warning of impending migraine with aura usually consists of visual changes, flashing lights, or diplopia. The other manifestations are not associated with an impending migraine with aura.
DIF: Understanding/Comprehension REF: 854
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?
a.
Bronchial asthma
b.
Prinzmetal’s angina
c.
Diabetes mellitus
d.
Chronic kidney disease
ANS: B
Sumatriptan succinate effectively reduces pain and other associated symptoms of migraine headache by binding to serotonin receptors and triggering cranial vasoconstriction. Vasoconstrictive effects are not confined to the cranium and can cause coronary vasospasm in clients with Prinzmetal’s angina. The other conditions would not affect the client’s treatment.
DIF: Applying/Application REF: 856
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?
a.
Atonic seizure
b.
Tonic-clonic seizure
c.
Myoclonic seizure
d.
Absence seizure
ANS: B
Seizure activity that begins with stiffening of the arms and legs, followed by loss of consciousness and jerking of all extremities, is characteristic of a tonic-clonic seizure. An atonic seizure presents as a sudden loss of muscle tone followed by postictal confusion. A myoclonic seizure presents with a brief jerking or stiffening of extremities that may occur singly or in groups. Absence seizures present with automatisms, and the client is unaware of his or her environment.
DIF: Understanding/Comprehension REF: 858
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take?
a.
Start fluids via a large-bore catheter.
b.
Turn the client’s head to the side.
c.
Administer IV push diazepam.
d.
Prepare to intubate the client.
ANS: B
The nurse should turn the client’s head to the side to prevent aspiration and allow drainage of secretions. Anticonvulsants are administered on a routine basis if a seizure is sustained. If the seizure is sustained (status epilepticus), the client must be intubated and should be administered oxygen, 0.9% sodium chloride, and IV push lorazepam or diazepam.
DIF: Applying/Application REF: 861
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer?
a.
Atenolol (Tenormin)
b.
Lorazepam (Ativan)
c.
Phenytoin (Dilantin)
d.
Lisinopril (Prinivil)
ANS: B
Initially, intravenous lorazepam is administered to stop motor movements. This is followed by the administration of phenytoin. Atenolol, a beta blocker, and lisinopril, an angiotensin-converting enzyme inhibitor, are not administered for seizure activity. These medications are typically administered for hypertension and heart failure.
DIF: Applying/Application REF: 861
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?
a.
“To prevent complications, I will drink at least 2 liters of water daily.”
b.
“This medication will stop me from getting an aura before a seizure.”
c.
“I will not drive a motor vehicle while taking this medication.”
d.
“Even when my seizures stop, I will continue to take this drug.”
ANS: D
Discontinuing antiepileptic drugs can lead to the recurrence of seizures or status epilepticus. The client does not need to drink more water and can drive while taking this medication. The medication will not stop an aura before a seizure.
DIF: Applying/Application REF: 861
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?
a.
“I will wear my medical alert bracelet at all times.”
b.
“While taking my epilepsy medications, I will not drink any alcoholic beverages.”
c.
“I will tell my doctor about my prescription and over-the-counter medications.”
d.
“If I am nauseated, I will not take my epilepsy medication.”
ANS: D
The nurse must emphasize that antiepileptic drugs must be taken even if the client is nauseous. Discontinuing the medication can predispose the client to seizure activity and status epilepticus. The client should not drink alcohol while taking seizure medications. The client should wear a medical alert bracelet and should make the doctor aware of all medications to prevent complications of polypharmacy.
DIF: Applying/Application REF: 860
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask?
a.
“Do you live in a crowded residence?”
b.
“When was your last tetanus vaccination?”
c.
“Have you had any viral infections recently?”
d.
“Have you traveled out of the country in the last month?”
ANS: A
Meningococcal meningitis tends to occur in multiple outbreaks. It is most likely to occur in areas of high-density population, such as college dormitories, prisons, and military barracks. A tetanus vaccination would not place the client at increased risk for meningitis or protect the client from meningitis. A viral infection would not lead to bacterial meningitis but could lead to viral meningitis. Simply knowing if the client traveled out of the country does not provide enough information. The nurse should ask about travel to specific countries in which the disease is common, for example, sub-Saharan Africa.
DIF: Applying/Application REF: 863
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?
a.
“His masklike face makes it difficult to communicate, so I will use a white board.”
b.
“He should not socialize outside of the house due to uncontrollable drooling.”
c.
“This disease is associated with anxiety causing increased perspiration.”
d.
“He may have trouble chewing, so I will offer bite-sized portions.”
ANS: D
Because chewing and swallowing can be problematic, small frequent meals and a supplement are better for meeting the client’s nutritional needs. A masklike face and drooling are common in clients with Parkinson disease. The client should be encouraged to continue to socialize and communicate as normally as possible. The wife should understand that the client’s masklike face can be misinterpreted and additional time may be needed for the client to communicate with her or others. Excessive perspiration is also common in clients with Parkinson disease and is associated with the autonomic nervous system’s response.
DIF: Applying/Application REF: 868
A nurse plans care for a client with Parkinson disease. Which intervention should the nurse include in this client’s plan of care?
a.
Ambulate the client in the hallway twice a day.
b.
Ensure a fluid intake of at least 3 liters per day.
c.
Teach the client pursed-lip breathing techniques.
d.
Keep the head of the bed at 30 degrees or greater.
ANS: D
Elevation of the head of the bed will help prevent aspiration. The other options will not prevent aspiration, which is the greatest respiratory complication of Parkinson disease, nor do these interventions address any of the complications of Parkinson disease. Ambulation in the hallway is usually implemented to prevent venous thrombosis. Increased fluid intake flushes out toxins from the client’s blood. Pursed-lip breathing increases exhalation of carbon dioxide.
DIF: Applying/Application REF: 870
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?
a.
“It will allow your mother to live independently for several more years.”
b.
“It is used to halt the advancement of Alzheimer’s disease but will not cure it.”
c.
“It will not improve her dementia but can help control emotional responses.”
d.
“It is used to improve short-term memory but will not improve problem solving.”
ANS: C
Drug therapy is not effective for treating dementia or halting the advancement of Alzheimer’s disease. However, certain drugs may help suppress emotional disturbances and psychiatric manifestations. Medication therapy may not allow the client to safely live independently.
DIF: Applying/Application REF: 877
A nurse assesses a client with Alzheimer’s disease who is recently admitted to the hospital. Which psychosocial assessment should the nurse complete?
a.
Assess religious and spiritual needs while in the hospital.
b.
Identify the client’s ability to perform self-care activities.
c.
Evaluate the client’s reaction to a change of environment.
d.
Ask the client about relationships with family members.
ANS: C
As Alzheimer’s disease progresses, the client experiences changes in emotional and behavioral affect. The nurse should be alert to the client’s reaction to a change in environment, such as being hospitalized, because the client may exhibit an exaggerated response, such as aggression, to the event. The other assessments should be completed but are not as important as assessing the client’s reaction to environmental change.
DIF: Applying/Application REF: 875
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?
a.
“I see you are still hungry. I will get you some toast.”
b.
“You ate your breakfast 30 minutes ago.”
c.
“It appears you are confused this morning.”
d.
“Your family will be here soon. Let’s get you dressed.”
ANS: A
Use of validation therapy with clients who have Alzheimer’s disease involves acknowledgment of the client’s feelings and concerns. This technique has proved more effective in later stages of the disease, when using reality orientation only increases agitation. Telling the client that he or she already ate breakfast may agitate the client. The other statements do not validate the client’s concerns.
DIF: Applying/Application REF: 876
A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication?
a.
Serum electrolyte levels
b.
Kidney function tests
c.
Complete blood cell count
d.
Antinuclear antibodies
ANS: B
Adverse effects of levetiracetam include coordination problems and renal toxicity. The other laboratory tests are not affected by levetiracetam.
DIF: Applying/Application REF: 860
