Resource 1 Flashcards
The nurse is caring for a patient with migraine headaches. Which medication should the nurse expect to be prescribed prophylactically for this patient?
- propranolol hydrochloride (Inderal)
- acetaminophen (Tylenol)
- zolmitriptan (Zomig)
- sumatriptan (Imitrex)
Correct Answer: 1
The nurse is planning a seminar about headaches for a local civic group. What type of headache should the nurse describe as having a strong familial connection, affects females three to one over males, and results in lost productivity?
- migraine
- cluster
- stress
- sinus
Correct Answer: 1
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 only when you have prodromal symptoms indicating the onset of a
migraine headache.”
“Take this drug as ordered, even when feeling well, to prevent vascular changes
associated with migraine headaches.”
“This drug will relieve the pain during the aura phase soon after a headache has
started.”
“This medication will have no effect on your heart rate or blood pressure because
you are taking it for migraines.”
ANS: B
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. V ertigo
b. Lethargy
c. Visual disturbances
d. Numbness of the tongue
Ans; C
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
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?
a. “Place a warm compress on your forehead at the onset of the headache.”
b. “Wear dark sunglasses when you are in brightly lit spaces.”
c. “Lie down in a darkened room when you experience a headache.”
d. “Set your alarm to ensure you do not sleep longer than 6 hours at one time.”
ANS: C
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.)
a. “Increase your intake of caffeinated beverages.”
b. “Incorporate physical exercise into your daily routine.”
c. “Avoid all alcoholic beverages.”
d. “Participate in a smoking cessation program.” e. “Increase your intake of fruits and vegetables.”
ANS: B, D, E
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye
b. Miosis
c. Abrupt loss of consciousness
d. Neck and shoulder tenderness
e. Nasal congestion
f. Exophthalmos
ANS: A, B, E
The nurse determines that teaching about management of migraine headaches has been effective when the patient says 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
ANS: C
A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action should the nurse take?
a. Teach about the use of triptan drugs.
b. Refer the patient for stress counseling.
c. Ask the patient to keep a headache diary.
d. Suggest the use of muscle-relaxation techniques.
ANS: C
The health care provider is considering the use of sumatriptan (Imitrex) for a 54-yr-old male patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
a. The patient drinks 1 to 2 cups of coffee daily.
b. The patient had a recent acute myocardial infarction.
c. The patient has had migraine headaches for 30 years.
d. The patient has taken topiramate (Topamax) for 2 months.
ANS: B
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
9. The nurse caring for a patient with a migraine headache who has a history of myocardial infarction for the past year would question which of the following medications that has been prescribed for the migraine headache? A) Rizatriptan (Maxalt) B) Naratriptan (Amerge) C) Sumatriptan succinate (Imitrex) D) Zolmitriptan (Zomig)
Ans: C
- A nurse is teaching home care instructions to a patient experiencing migraine headache. The patient questions the nurse regarding alcohol consumption. The nurse would be correct in telling the patient that alcohol causes which of the following physiological changes?
A) Causes hormone fluctuation
B) Vasodilation of the blood vessels
C) Excitatory effect on the central nervous system (CNS)
D) Diminishes endorphins in the brain
Ans: B
A patient is being treated for a common neurological disease that is characterized by abnormal cell firing in the brain. For what should the nurse assess in this patient?
- loss of consciousness
- seizures
- decerebrate posturing
- headache
Correct Answer: 2
The nurse is observing a patient who is having a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips. The seizure lasts less than a minute. How should the nurse categorize this seizure?
- absence
- partial
- tonic‒clonic
- status epilepticus
Correct Answer: 1
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
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
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
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
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
The nurse will anticipate teaching a patient with a possible seizure disorder about which test?
a. Cerebral angiography
b. Evoked potential studies
c. Electromyography (EMG)
d. Electroencephalography (EEG)
ANS: D
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
A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach any more. It will be too upsetting if I have a seizure at work.” Which response by the nurse specifically addresses the patient’s concern?
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
- A patient reports feeling numbness and tingling of the left arm before experiencing a seizure. The nurse determines that this history is consistent with what type of seizure?
a. Focal
b. Atonic
c. Absence
d. Myoclonic
ANS: A
- The nurse observes a patient ambulating in the hospital hall when the patient’s arms and legs suddenly jerk and the patient falls to the floor. The nurse will first
a. assess the patient for a possible injury.
b. give the scheduled divalproex (Depakote).
c. document the timing and description of the seizure.
d. notify the patient’s health care provider about the seizure.
ANS: A
Which prescribed intervention will the nurse implement first for a patient in the emergency department who is experiencing continuous tonic-clonic seizures?
a. .Give phenytoin (Dilantin) 100 mg IV.
b. Monitor level of consciousness (LOC).
c. Administer lorazepam (Ativan) 4 mg IV.
d. Obtain computed tomography (CT) scan.
ANS: C
Which information about a patient who has a new prescription for phenytoin (Dilantin) indicates that the nurse should consult with the health care provider before administration of the medication?
a. Patient has tonic-clonic seizures.
b. Patient experiences an aura before seizures.
c. Patient has minor elevations in the liver function tests.
d. Patient’s most recent blood pressure is 156/92 mm Hg.
ANS: C
A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient’s assigned room (select all that apply)?
a. Side-rail pads d. Suction tubing
b. Tongue blade e. Urinary catheter
c. Oxygen mask f. Nasogastric tube
ANS: A, C, D
The physician has ordered an anticonvulsant to prevent posttraumatic seizures in a patient who has sustained a missile injury to the head. Which of the following medications is classified as an anticonvulsant? A) Mestinon (pyridostigmine) B) Dilantin (phenytoin) C) Sinemet (levodopa-carbidopa) D) Cogentin (benztropine)
Ans: B
A patient with an acute exacerbation of systemic lupus erythematosus (SLE) is hospitalized with incapacitating fatigue, acute hand and wrist pain, and proteinuria. The health care provider prescribes prednisone (Deltasone) 40 mg twice daily. Which nursing action should be included in the plan of care?
a. Institute seizure precautions.
b. Reorient to time and place PRN.
c. Monitor intake and output.
d. Place on cardiac monitor.
Correct Answer: C
14. A nurse cares for a client who presents with an acute exacerbation of multiple sclerosis (MS). Which prescribed medication should the nurse prepare to administer? a. Baclofen (Lioresal) b. Interferon beta-1b (Betaseron) c. Dantrolene sodium (Dantrium) d. Methylprednisolone (Medrol)
ANS: D
A nurse assesses a client with multiple sclerosis after administering prescribed fingolimod (Gilenya). For which adverse effect should the nurse monitor?
a. Peripheral edema
b. Black tarry stools
c. Bradycardia
d. Nausea and vomiting
ANS: C
A nurse is teaching a client with multiple sclerosis who is prescribed cyclophosphamide (Cytoxan) and methylprednisolone (Medrol). Which statement should the nurse include in this client’s discharge teaching?
a. “Take warm baths to promote muscle relaxation.”
b. “Avoid crowds and people with colds.”
c. “Relying on a walker will weaken your gait.”
d. “Take prescribed medications when symptoms occur.”
ANS: B
A woman who has multiple sclerosis (MS) asks the nurse about risks associated with pregnancy. Which response by the nurse is accurate?
a. “MS symptoms may be worse after the pregnancy.”
b. “Women with MS frequently have premature labor.”
c. “MS is associated with an increased risk for congenital defects.”
d. “Symptoms of MS are likely to become worse during pregnancy.”
ANS: A
A 33-yr-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
a. Recommendation to drink at least 4 L of fluid daily
b. Need to avoid driving or operating heavy machinery
c. How to draw up and administer injections of the medication
d. Use of contraceptive methods other than oral contraceptives
ANS: C
Which information about a 60-yr-old patient with multiple sclerosis indicates that the nurse should consult with the health care provider before giving the prescribed dose of dalfampridine (Ampyra)?
a. The patient walks a mile each day for exercise.
b. The patient complains of pain with neck flexion.
c. The patient has an increased serum creatinine level.
d. The patient has the relapsing-remitting form of MS.
ANS: C
Which action will the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?
a. Encourage a decreased evening intake of fluid.
b. Teach the patient how to use the Credé method.
c. Suggest the use of adult incontinence briefs for nighttime only.
d. Assist the patient to the commode every 2 hours during the day.
ANS: B
When obtaining a health history and physical assessment for a 36-year-old female patient with possible multiple sclerosis (MS), the nurse should
a. assess for the presence of chest pain.
b. inquire about urinary tract problems.
c. inspect the skin for rashes or discoloration.
d. ask the patient about any increase in libido.
ANS: B
Upon admission, the physician orders baclofen (Lioresal) for a patient diagnosed with multiple sclerosis. The nurse knows that which of the following is an expected outcome of this medication?
A) Reduction in the appearance of new lesions on the MRI
B) Decreased muscle spasms in the lower extremities
C) Increased muscle strength in the upper extremities
D) Limited severity and duration of exacerbations
Ans: B
The nurse assessing a patient with multiple sclerosis understands that due to the pathophysiology of this disease process which of the following is the expected primary finding on the MRI? A) Subarachnoid hemorrhage B) Presence of multiple plaques C) Atrophy of the caudate nuclei D) Presence of a tumor
Ans: B
What basic information will the nurse caring for a patient recently diagnosed with multiple sclerosis (MS) provide to him?
A) It is a degenerative disease of the nervous system.
B) It usually occurs more frequently in men.
C) It has an acute onset.
D) It is caused by a bacterial infection.
Ans: A
A 37-year-old teacher is hospitalized with complaints of weakness, incoordination, dizziness, and loss of balance. The diagnosis is multiple sclerosis (MS). Which of the following signs and symptoms, revealed during the history and physical assessment, is typical of MS?
A) Diplopia, history of increased fatigue, and decreased or absent deep tendon reflexes
B) Flexor spasm, clonus, and negative Babinski’s reflex
C) Blurred vision, intention tremor, and urinary hesitancy
D) Hyperactive abdominal reflexes and history of unsteady gait and episodic paresthesia in both legs
Ans: C
The nurse would expect to find which of the following symptoms when assessing a 38-year-old patient diagnosed with multiple sclerosis? A) Vision changes B) Absent deep tendon reflexes C) Tremors at rest D) Flaccid muscles
Ans: A
When teaching the patient with multiple sclerosis how to reduce fatigue, the nurse should tell him to:
A) Take a hot bath.
B) Rest in an air-conditioned room.
C) Increase the dose of muscle relaxants.
D) Avoid naps during the day.
Ans: B
When teaching the patient with newly diagnosed multiple sclerosis (MS) about the disease, the nurse explains that
a. MS is a congenitally acquired illness that causes progressive neurologic deterioration.
b. impulses travel too fast over nerves that have lost their myelin coat and cause overstimulation of muscle fibers.
c. autoimmune processes cause gradual destruction of the myelin sheath of nerves in the brain and spinal cord.
d. antibodies are produced against acetylcholine receptors at the synapse and result in blocked muscle contraction.
Correct Answer: C
- A nurse cares for a client with amyotrophic lateral sclerosis (ALS). The client states, “I do not want to be placed on a mechanical ventilator.” How should the nurse respond?
a. “You should discuss this with your family and health care provider.”
b. “Why are you afraid of being placed on a breathing machine?”
c. “Using the incentive spirometer each hour will delay the need for a ventilator.”
d. “What would you like to be done if you begin to have difficulty breathing?”
ANS: D
A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
a. Observe for agitation and paranoia.
b. Assist with active range of motion (ROM).
c. Give muscle relaxants as needed to reduce spasms.
d. Use simple words and phrases to explain procedures.
ANS: B
The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient?
- “Do you recall if any of your relatives had difficulty holding on to things with their hands?”
- “Do you remember what you ate for breakfast this morning?”
- “Is it painful to flex your chin to your chest?”
- “Did your muscle weakness first occur in your arms or in your legs?”
Correct Answer: 1
- 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
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
A patient with Parkinson’s disease has bradykinesia. Which action will the nurse include in the plan of care?
a. Instruct the patient in activities that can be done while lying or sitting.
b. Suggest that the patient rock from side to side to initiate leg movement.
c. Have the patient take small steps in a straight line directly in front of the feet.
d. Teach the patient to keep the feet in contact with the floor and slide them forward.
ANS: B
A 62-yr-old patient who has Parkinson’s disease is taking bromocriptine (Parlodel). Which information obtained by the nurse may indicate a need for a decrease in the dosage?
a. The patient has a chronic dry cough.
b. The patient has four loose stools in a day.
c. The patient develops a deep vein thrombosis.
d. The patient’s blood pressure is 92/52 mm Hg.
ANS: D
When a 74-yr-old patient is seen in the health clinic with new development of a stooped posture, shuffling gait, and pill rolling–type tremor, the nurse will anticipate teaching the patient about
a. oral corticosteroids.
b. antiparkinsonian drugs.
c. magnetic resonance imaging (MRI).
d. electroencephalogram (EEG) testing.
ANS: B
A patient is being treated with carbidopa/levodopa (Sinemet) for Parkinson’s disease. Which information indicates a need for change in the medication or dosage?
a. Shuffling gait c. Cogwheel rigidity of limbs
b. Tremor at rest d. Uncontrolled head movement
ANS: D
Which nursing diagnosis is of highest priority for a patient with Parkinson’s disease who is unable to move the facial muscles?
a. Activity intolerance
b. Self-care deficit: toileting
c. Ineffective self-health management
d. Imbalanced nutrition: less than body requirements
ANS: D
The nurse is conducting a seminar on Alzheimer disease (AD) with a group of community members. How should the nurse describe this health problem?
Standard Text: Select all that apply.
- The incidence of AD increases with age.
- AD tends to run in families.
- AD is more common in men.
- AD is caused by a virus.
- AD is caused by environmental contaminants.
Correct Answer: 1,2
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
. 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
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?
a. “This is a sign of fatigue. The client would benefit from a daily nap.”
b. “Engage the client in scheduled activities throughout the day.”
c. “It sounds like this is difficult for you. I will consult the social worker.”
d. “The provider can prescribe a mild sedative for restlessness.”
ANS: B
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?
a. “Allow the client to rest most of the day.”
b. “Place a padded throw rug at the bedside.”
c. “Install deadbolt locks on all outside doors.”
d. “Provide a high-calorie and high-protein diet.”
ANS: C
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
A patient is being evaluated for Alzheimer’s disease (AD). The nurse explains to the patient’s adult children that
a. the most important risk factor for AD is a family history of the disorder.
b. a diagnosis of AD is made only after other causes of dementia are ruled out.
c. new drugs have been shown to reverse AD deterioration dramatically in some patients.
d. brain atrophy detected by magnetic resonance imaging (MRI) would confirm the diagnosis of AD.
ANS: B
A patient who has severe Alzheimer’s disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care?
a. Encourage the patient to discuss events from the past.
b. Maintain a consistent daily routine for the patient’s care.
c. Reorient the patient to the date and time every 2 to 3 hours.
d. Provide the patient with current newspapers and magazines.
ANS: B
A patient with Alzheimer’s disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care?
a. Reorient the patient several times daily.
b. Have the family bring in familiar items.
c. Place the patient in a room close to the nurses’ station.
d. Ask the patient why the wandering episodes have occurred.
ANS: C
After change-of-shift report on the Alzheimer’s disease/dementia unit, which patient will the nurse assess first?
a. Patient who has not had a bowel movement for 5 days
b. Patient who has a stage II pressure ulcer on the coccyx
c. Patient who is refusing to take the prescribed medications
d. Patient who developed a new cough after eating breakfast
ANS: D
