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? - correct answer ...
EXAM 3 NUR 1212
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? - correct answer Tonic-clonic seizure
A nurse witnesses a client begin to experience a tonic-clonic seizure and loss of consciousness. Which action should the nurse take? - correct answer Turn the client's head to the side.
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? - correct answer Lorazepam (Ativan)
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? - correct answer "Even when my seizures stop, I will continue to take this drug."
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? - correct answer "If I am nauseated, I will not take my epilepsy medication."
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? - correct answer "Do you live in a crowded residence?"
A nurse assesses a client after administering prescribed levetiracetam (Keppra). Which laboratory tests should the nurse monitor for potential adverse effects of this medication? - correct answer Kidney function tests
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) - correct answer Have suction equipment at the bedside. Keep bed rails up at all times.
Ensure that the client has IV access.
A nurse evaluates the results of diagnostic tests on a client's cerebrospinal fluid (CSF). Which fluid results
alerts the nurse to possible viral meningitis? (Select all that apply.) - correct answer Clear
Increased protein level
Normal glucose level
A nurse assesses a client who is experiencing an absence seizure. For which clinical manifestations should the nurse assess? (Select all that apply.) - correct answer Lip smacking
Picking at clothing
Patting of the hand on the leg
A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) - correct answer Surgical mask
Gloves
A nurse assesses clients on a medical-surgical unit. Which clients should the nurse identify as at risk for secondary seizures? (Select all that apply.) - correct answer A 26-year-old woman with a left temporal brain tumor
A 38-year-old male client in an alcohol withdrawal program
A 42-year-old football player with a traumatic brain injury
A nurse assesses a client who is recovering from the implantation of a vagal nerve stimulation device. For which clinical manifestations should the nurse assess as common complications of this procedure? (Select all that apply.) - correct answer Hoarseness
Dysphagia
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) - correct answer Sodium level Liver enzymes
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs
of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) - correct answer Dilated pupils
Widened pulse pressure
Bradycardia
A nurse promotes the prevention of lower back pain by teaching clients at a community center. Which instruction should the nurse include in this education? - correct answer "Participate in an exercise program to strengthen muscles."
A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? - correct answer Apply a heating pad for 20 minutes at least four times daily.
A nurse assesses a client who is recovering from a diskectomy 6 hours ago. Which assessment finding should the nurse address first? - correct answer Bladder palpated above pubis
A nurse assesses clients at a community center. Which client is at greatest risk for lower back pain? - correct answer A 45-year-old male with osteoarthritis
A nurse teaches a client who is recovering from a spinal fusion. Which statement should the nurse include in this client's postoperative instructions? - correct answer "Wear your
brace whenever you are out of bed."
A nurse assesses a client who is recovering from anterior cervical diskectomy and fusion. Which complication should alert the nurse to urgently communicate with the health care provider? - correct answer Auscultated stridor
A nurse assesses a client with a spinal cord injury at level T5. The client's blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? - correct answer Palpate the bladder for distention.
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