59-12

Created by Quizcard1 

Upgrade to
remove ads

33 terms

1. A hospitalized patient complains of a moderate bilateral headache that radiates from the base of the skull. Which of the following medications ordered on a PRN basis for the patient should the nurse administer initially?
a. Lorazepam (Ativan)
b. Acetaminophen (Tylenol)
c. Morphine sulfate (Roxanol)
d. Butalbital and aspirin (Fiorinal)

Correct Answer: B
Rationale: The patient's symptoms are consistent with a tension headache, and initial therapy usually involves a nonopioid analgesic such as acetaminophen, sometimes combined with a sedative or muscle relaxant. Lorazepam may be used in conjunction with acetaminophen but would not be appropriate as the initial monotherapy. Morphine sulfate and Fiorinal would be more appropriate for a headache that did not respond to a nonopioid analgesic.

Cognitive Level: Application Text Reference: p. 1530
Nursing Process: Implementation NCLEX: Physiological Integrity

2. A patient seen at the health clinic with a severe migraine headache tells the nurse about having four similar headaches in the last 3 months. The patient says, "I am afraid to make social plans because I never know when I will have these headaches." The most appropriate nursing action at this time is to
a. refer the patient for counseling to assist with stress reduction.
b. ask the patient to keep a diary with details about headaches.
c. encourage the patient to learn muscle-relaxation techniques to minimize headache frequency.
d. teach the patient about the effectiveness of the triptan drugs in treating migraine headaches.

Correct Answer: B
Rationale: The initial nursing action should be further assessment of the precipitating causes of the headaches, quality and location of pain, etc. Stress reduction, muscle relaxation, and the triptan drugs may be helpful, but more assessment is needed.

Cognitive Level: Application Text Reference: p. 1532
Nursing Process: Implementation NCLEX: Physiological Integrity

3. After teaching a patient about management of migraine headaches, the nurse determines that the teaching has been effective when the patient says,
a. "I will take the topiramate (Topamax) as soon as any headaches start."
b. "The sumatriptan (Imitrex) will help to increase the blood flow to my brain."
c. "I will try to lie down someplace dark and quiet when the headaches begin."
d. "A glass of wine might help me relax and prevent headaches from developing."

Correct Answer: C
Rationale: It is recommended that the patient with a migraine rest in a dark, quiet area. Topamax is used to prevent migraines and must be taken for several months to determine effectiveness. Blood flow to the brain is decreased by the triptan drugs. Alcohol may precipitate migraine headaches.

Cognitive Level: Application Text Reference: p. 1532
Nursing Process: Evaluation NCLEX: Physiological Integrity

4. When a patient is being evaluated for new onset cluster-type headaches, the nurse will anticipate
a. scheduling a magnetic resonance imaging (MRI) of the brain.
b. teaching the patient about electromyelography (EMG).
c. obtaining a detailed patient history.
d. arranging for a cerebral angiogram.

Correct Answer: C
Rationale: Diagnosis of cluster headache is made primarily on the basis of the patient's symptoms. Other diagnostic tests are only obtained if an underlying disorder is suspected as the cause of the headache.

Cognitive Level: Application Text Reference: p. 1529
Nursing Process: Planning NCLEX: Physiological Integrity

5. A patient experiences cluster headaches that occur for 2 months every year. During assessment of the patient who is experiencing a headache episode, the nurse would expect to find
a. nuchal rigidity.
b. projectile vomiting.
c. unilateral eyelid swelling.
d. throbbing, bilateral facial pain.

Correct Answer: C
Rationale: 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 increases in intracranial pressure (ICP). Unilateral sharp, stabbing pain, rather than throbbing pain, is characteristic of cluster headaches.

Cognitive Level: Comprehension Text Reference: pp. 1528-1529
Nursing Process: Assessment NCLEX: Physiological Integrity

6. The health care provider is considering the use of sumatriptan (Imitrex) for a patient with migraine headaches. Which information obtained by the nurse is most important to report to the health care provider?
a. The patient has a history of a recent acute myocardial infarction.
b. The patient has had migraine headaches for 30 years.
c. The patient has been taking topiramate (Topamax) for 2 months.
d. The patient has at least 1 to 2 cups of coffee daily.

Correct Answer: A
Rationale: The triptans cause coronary artery vasoconstriction and should be avoided in patients with coronary artery disease. The other information will be reported to the health care provider, but none is an indication that sumatriptan would be an inappropriate treatment.

Cognitive Level: Application Text Reference: p. 1530
Nursing Process: Assessment NCLEX: Physiological Integrity

7. A patient has a tonic-clonic seizure while the nurse is in the patient's room. During the seizure, it is important for the nurse to
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. avoid touching the patient to prevent further nervous system stimulation.
d. time and observe and record the details of the seizure and postictal state.

Correct Answer: D
Rationale: Because 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.

Cognitive Level: Application Text Reference: pp. 1536, 1539
Nursing Process: Implementation NCLEX: Physiological Integrity

8. The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to
a. document the timing and description of the seizure.
b. notify the patient's health care provider about the seizure.
c. give the scheduled dose of divalproex (Depakote).
d. assess the patient for a possible head injury.

Correct Answer: D
Rationale: The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications are also appropriate actions, but the initial action should be assessment for injury.

Cognitive Level: Application Text Reference: p. 1535
Nursing Process: Implementation NCLEX: Physiological Integrity

9. After experiencing a generalized tonic-clonic seizure in the classroom, an elementary school teacher is evaluated and diagnosed with idiopathic epilepsy. The patient cries and tells the nurse, "I can not teach anymore. It will be too difficult for the students if this happens again at work." The most appropriate nursing diagnosis for the patient is
a. anxiety related to loss of control during seizures.
b. hopelessness related to diagnosis of chronic illness.
c. disturbed body image related to new diagnosis of a seizure disorder.
d. ineffective role performance related to misinformation about epilepsy.

Correct Answer: D
Rationale: The data indicate that the patient has ineffective role performance caused by inadequate information about the disease because most patients are able to control seizures with medication. Because the focus of the patient's statement is on career issues, this is a more appropriate diagnosis than anxiety, hopelessness, or disturbed body issues.

Cognitive Level: Application Text Reference: p. 1541
Nursing Process: Diagnosis NCLEX: Psychosocial Integrity

10. The health care provider prescribes phenytoin (Dilantin) for control of complex partial seizures. After the nurse has taught the patient about phenytoin, which patient statement indicates understanding of the medication?
a. "I should use soft swabs rather than a toothbrush to clean my mouth."
b. "After I have a seizure, I should call an ambulance to take me to the hospital."
c. "I may need to have my blood taken frequently to check the level of the Dilantin."
d. "I will take the medication at the beginning of the seizure when I experience an aura."

Correct Answer: C
Rationale: Serum levels of phenytoin may be checked to ascertain that a therapeutic level of the medication is achieved. Gingival hyperplasia associated with phenytoin use can be decreased by frequent brushing and flossing. Most seizures do not require hospitalization. The phenytoin is taken regularly to prevent seizures, not acutely when seizures occur.

Cognitive Level: Application Text Reference: p. 1536
Nursing Process: Evaluation NCLEX: Physiological Integrity

11. When a patient experiences a generalized tonic-clonic seizure in the emergency department after a head injury, all of the following orders are received. Which one will the nurse implement first?
a. Send to radiology for computed tomography (CT) scan.
b. Administer midazolam (Versed).
c. Check capillary blood glucose.
d. Monitor level of consciousness (LOC).

Correct Answer: B
Rationale: To prevent ongoing seizures, the nurse should administer rapidly acting antiseizure medications such as the benzodiazepines. A CT scan is appropriate, but prevention of any seizure activity during the CT scan is necessary. Although the capillary blood glucose may offer information about the cause of the seizure, the initial nursing action is to decrease the risk for further seizures. Monitoring level of consciousness is important, but the highest priority is to decrease seizure risk.

Cognitive Level: Application Text Reference: p. 1537
Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient found in a tonic-clonic seizure reports afterward that the seizure was preceded by numbness and tingling of the arm. The nurse knows that this finding indicates a(n) _____ seizure.
a. absence
b. simple partial
c. complex partial
d. generalized myoclonic

Correct Answer: C
Rationale: The initial symptoms of a complex partial seizure involve clinical manifestations that are localized to a particular part of the body or brain. In addition, an alteration in consciousness is always manifested. Symptoms of an absence seizure are staring and a brief loss of consciousness. During a simple partial seizure, the patient does not lose consciousness. A generalized myoclonic seizure is characterized by a sudden jerk of the body or extremities.

Cognitive Level: Comprehension Text Reference: p. 1535
Nursing Process: Assessment NCLEX: Physiological Integrity

13. 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
Rationale: The primary pathology in MS is an autoimmune process that leads to loss of the myelin sheath and results in decreased nerve transmission. Although MS susceptibility does appear to be inherited, the disease is not congenital because the interaction of multiple factors precipitates MS development. Impulse transmission along nerve fibers is slowed. Antibodies to acetylcholine receptors do not cause MS.

Cognitive Level: Comprehension Text Reference: p. 1542
Nursing Process: Implementation NCLEX: Physiological Integrity

14. When obtaining a health history and physical assessment for a patient with possible multiple sclerosis (MS), the nurse should
a. confirm patient information with family members.
b. ask about a recent history of temperature spikes.
c. question the patient about any leg weakness or spasm.
d. determine whether hypersexuality has caused problems.

Correct Answer: C
Rationale: Extremity weakness or spasms are common motor symptoms of MS. Memory deficit and confusion are not symptoms of MS, and the patient will be an accurate historian. Although viral infection appears to trigger the onset of MS in some patients, temperature spikes are not associated with viral illness. Decreased libido and diminished sexual response are common MS symptoms.

Cognitive Level: Application Text Reference: p. 1543
Nursing Process: Assessment NCLEX: Physiological Integrity

15. A 28-year-old woman has had multiple sclerosis (MS) for 3 years and wants to have children before her disease worsens. When she asks about the risks associated with pregnancy, the nurse explains that
a. MS is associated with a slightly increased risk for congenital defects.
b. symptoms of MS are likely to become worse during her pregnancy.
c. women with MS frequently have premature labor.
d. MS symptoms may be worse after the pregnancy.

Correct Answer: D
Rationale: During the postpartum period, women with MS are at greater risk for exacerbation of symptoms. There is no increased risk for congenital defects in infants born of mothers with MS. Symptoms of MS may improve during pregnancy. Pregnancy, labor, and delivery are not affected by MS.

Cognitive Level: Application Text Reference: p. 1543
Nursing Process: Implementation
NCLEX: Health Promotion and Maintenance

16. A patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). In planning the patient teaching necessary with the use of the drug, the nurse recognizes that the patient will need to be taught
a. how to draw up and administer injections of the medication.
b. use of contraceptive methods other than oral contraceptives for birth control.
c. to plan laboratory monitoring of CBC, chemistries, and liver function every 3 months.
d. that the drug will control symptoms but has no effect on the progression of the disease.

Correct Answer: A
Rationale: Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice for birth control. No laboratory monitoring is needed. The purpose of the medication is to modify the MS disease process.

Cognitive Level: Application Text Reference: p. 1544
Nursing Process: Planning NCLEX: Physiological Integrity

17. When planning care for a patient with MS who has a nursing diagnosis of risk for activity intolerance related to extremity weakness secondary to stress, the most appropriate patient goal is
a. "The patient will express minimal stress level."
b. "Strength in arms and legs will be maintained."
c. "The patient will complete ADLs without fatigue."
d. "Intake of high-nutrition foods will be adequate."

Correct Answer: C
Rationale: Because the nurse has identified the patient's problem as activity intolerance, a patient goal that indicates improvement in activity tolerance, such as ability to accomplish ADLs without fatigue, is most appropriate. The other goals are appropriate for nursing diagnoses such as ineffective coping, impaired physical mobility, and inadequate nutritional intake.

Cognitive Level: Application Text Reference: pp. 1546-1547
Nursing Process: Planning NCLEX: Physiological Integrity

18. A patient with multiple sclerosis (MS) has a nursing diagnosis of urinary retention related to sensorimotor deficits. An appropriate nursing intervention for this problem is to
a. decrease fluid intake in the evening.
b. teach the patient how to use the Credé method.
c. suggest the use of incontinence briefs for nighttime use only.
d. assist the patient to the commode every 2 hours during the day.

Correct Answer: B
Rationale: The Credé method can be used to improve bladder emptying. Decreasing fluid intake will not improve bladder emptying and may increase risk for urinary tract infection (UTI) and dehydration. The use of incontinence briefs and frequent toileting will not improve bladder emptying.

Cognitive Level: Application Text Reference: p. 1548
Nursing Process: Planning NCLEX: Physiological Integrity

19. The nurse identifies the nursing diagnosis of impaired physical mobility related to bradykinesia for a patient with Parkinson's disease. To assist the patient to ambulate safely, the nurse should
a. allow the patient to ambulate only with assistance.
b. instruct the patient to 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.

Correct Answer: B
Rationale: Rocking the body from side to side stimulates balance and improves mobility. The patient should initially be ambulated with assistance but might not require continual assistance with ambulation. The patient should maintain a wide base of support to help with balance. The patient should lift the feet and avoid a shuffling gait.

Cognitive Level: Application Text Reference: p. 1554
Nursing Process: Implementation NCLEX: Physiological Integrity

20. A patient who has been taking bromocriptine (Parlodel) and benztropine (Cogentin) for Parkinson's disease is experiencing a worsening of symptoms. The nurse will anticipate that patient may benefit from
a. complete drug withdrawal for a few weeks.
b. use of levodopa (L-dopa)-carbidopa (Sinemet).
c. withdrawal of anticholinergic therapy.
d. increasing the dose of bromocriptine.

Correct Answer: B
Rationale: After the dopamine receptor agonists begin to fail to relieve symptoms, the addition of L-dopa with carbidopa can be added to the regimen. Complete drug withdrawal will result in worsening of symptoms. Anticholinergic therapy should be continued to help maintain the balance between the actions of dopamine and acetylcholine. Increasing the dose of bromocriptine will increase the risk for toxic effects.

Cognitive Level: Comprehension Text Reference: p. 1551
Nursing Process: Planning NCLEX: Physiological Integrity

21. A patient with Parkinson's disease has decreased tongue mobility and an inability to move the facial muscles. The nurse recognizes that these impairments commonly contribute to the nursing diagnosis of
a. disuse syndrome related to loss of muscle control.
b. self-care deficit related to bradykinesia and rigidity.
c. impaired verbal communication related to difficulty articulating.
d. impaired oral mucous membranes related to inability to swallow.

Correct Answer: C
Rationale: The inability to use the tongue and facial muscles decreases the patient's ability to socialize or communicate needs. Disuse syndrome is not an appropriate nursing diagnosis because the patient is continuing to use the muscles as much as possible. There is no indication in the stem that the patient has a self-care deficit, bradykinesia, or rigidity. The oral mucous membranes will continue to be moist and should not be impaired by the patient's difficulty swallowing.

Cognitive Level: Application Text Reference: p. 1554
Nursing Process: Diagnosis NCLEX: Physiological Integrity

22. A patient has a new prescription for levodopa (L-dopa) to control symptoms of Parkinson's disease. Which assessment data obtained by the nurse may indicate a need for a decrease in the dose?
a. The patient has a chronic dry cough.
b. The patient has 4 loose stools in a day.
c. The patient develops a deep vein thrombosis.
d. The patient's blood pressure is 90/46 mm Hg.

Correct Answer: D
Rationale: Hypotension is an adverse effect of L-dopa, and the nurse should check with the health care provider before giving the medication. Diarrhea, cough, and deep vein thrombosis are not associated with L-dopa use.

Cognitive Level: Application Text Reference: p. 1552
Nursing Process: Evaluation NCLEX: Physiological Integrity

23. A patient with myasthenia gravis (MG) is admitted to the hospital with severe weakness and acute respiratory insufficiency. The health care provider performs a Tensilon test to distinguish between myasthenic crisis and cholinergic crisis. During the test, it will be most important to monitor the patient's
a. pupillary size.
b. muscle strength.
c. respiratory function.
d. level of consciousness (LOC).

Correct Answer: C
Rationale: Because the patient's respiratory insufficiency is life threatening, it will be most important to monitor respiratory function during the Tensilon test. Pupillary size and muscle strength may also be affected by the test but are not as important to monitor. LOC is not typically affected by MG, although the LOC may be affected by oxygenation in this patient.

Cognitive Level: Application Text Reference: p. 1556
Nursing Process: Assessment NCLEX: Physiological Integrity

24. When teaching a patient with myasthenia gravis (MG) about management of the disease, the nurse advises the patient to
a. anticipate the need for weekly plasmapheresis treatments.
b. protect the extremities from injury due to poor sensory perception.
c. do frequent weight-bearing exercise to prevent muscle atrophy.
d. perform necessary physically demanding activities in the morning.

Correct Answer: D
Rationale: Muscles are generally strongest in the morning, and activities involving muscle activity should be scheduled then. Plasmapheresis is not routinely scheduled but is used for myasthenia crisis or for in situations where corticosteroid therapy should be discontinued. There is no decrease in sensation with MG, and muscle atrophy does not occur because muscles are used during part of the day.

Cognitive Level: Application Text Reference: pp. 1555-1557
Nursing Process: Implementation NCLEX: Physiological Integrity

25. A hospitalized patient with myasthenia gravis (MG) has a nursing diagnosis of imbalanced nutrition: less than body requirements related to impaired swallowing. To promote nutrition, the nurse suggests that before meals the patient should avoid
a. watching television.
b. talking on the phone.
c. typing on the computer.
d. ambulating in the halls.

Correct Answer: B
Rationale: The same muscles are used for talking and swallowing, so the patient should avoid fatiguing the muscles of the mouth and throat before meals. The other activities will not affect the muscles used for chewing and swallowing.

Cognitive Level: Application Text Reference: pp. 1555-1556
Nursing Process: Implementation NCLEX: Physiological Integrity

26. A patient with restless legs syndrome (RLS) tells the nurse, "My leg pain and twitching keep me awake so much of the night, I am tired most of the day. Is there anything I can do?" Based on this information, which nursing diagnosis is most appropriate?
a. Ineffective role performance related to fatigue
b. Chronic pain related to RLS
c. Anxiety related to lack of knowledge about RLS treatment
d. Sleep deprivation related to leg pain and involuntary movement

Correct Answer: D
Rationale: The patient's statement indicates that daytime fatigue caused by lack of sleep is the major concern. The patient does not indicate concern with role performance. Although pain is a concern with RLS, the patient's concern is with the impact of pain on sleep. The patient is asking for information about treatment but does not appear anxious.

Cognitive Level: Application Text Reference: p. 1557
Nursing Process: Diagnosis NCLEX: Physiological Integrity

27. A patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
a. Observing for agitation and paranoia
b. Assisting the patient with active range of motion (ROM)
c. Using simple words and phrases to explain procedures
d. Administer muscle relaxants as needed for muscle spasms

Correct Answer: B
Rationale: ALS causes progressive muscle weakness, but assisting the patient to perform active ROM will help to maintain strength as long as possible. Psychotic symptoms such as agitation and paranoia are not associated with ALS. Cognitive function is not affected by ALS, and the patient's ability to understand procedures will not be impaired. Muscle relaxants will further increase muscle weakness and depress respirations.

Cognitive Level: Application Text Reference: p. 1558
Nursing Process: Planning NCLEX: Physiological Integrity

28. A 42-year-old patient who was adopted at birth is diagnosed with early Huntington's disease (HD). When teaching the patient, spouse, and children about this disorder, the nurse will provide information about the
a. use of levodopa-carbidopa (Sinemet) to help reduce HD symptoms.
b. need to take prophylactic antibiotics to decrease the risk for pneumonia.
c. lifestyle changes, such as increased exercise, that delay disease progression.
d. availability of genetic testing to determine the HD risk for the patient's children.

Correct Answer: D
Rationale: Genetic testing is available to determine whether an asymptomatic individual has the HD gene. The patient and family should be informed of the benefits and problems associated with genetic testing. Sinemet will increase symptoms of HD given that HD involves an increase in dopamine. The patient is at risk for pneumonia in the later stages of HD, but this patient has early HD. There are no effective treatments or lifestyle changes that delay the progression of symptoms in HD.

Cognitive Level: Application Text Reference: p. 1559
Nursing Process: Implementation NCLEX: Physiological Integrity

29. A hospitalized 24-year-old patient with a history of cluster headache awakens during the night with a severe stabbing headache. Which action should the nurse take first?
a. Notify the patient's health care provider immediately.
b. Start the ordered PRN oxygen at 9 L/min.
c. Give the ordered prn acetaminophen (Tylenol).
d. Put a moist hot pack on the patient's neck.

Correct Answer: B
Rationale: Acute treatment for cluster headache is administration of 100% oxygen at 7 to 9 L/min. If the patient obtains relief with the oxygen, there is no immediate need to notify the health care provider. Cluster headaches last only 60 to 90 minutes, so oral pain medications have minimal effect. Hot packs are helpful for tension headaches but are not as likely to reduce pain associated with a cluster headache.

Cognitive Level: Application Text Reference: pp. 1530-1531
Nursing Process: Implementation NCLEX: Physiological Integrity

30. Which information obtained about a 75-year-old patient with new-onset seizures will be of concern to the nurse when the patient is being started on therapy with phenytoin (Dilantin)?
a. The patient has a history of chronic hepatitis C.
b. The patient experienced menopause at age 52.
c. The patient lives alone in an assisted living facility.
d. The patient has had a recent right hemisphere stroke.

Correct Answer: A
Rationale: Phenytoin is metabolized by the liver, and the patient's age and history of hepatitis may increase the risk for toxic effects. The patient's age at menopause, living in an assisted living facility, and stroke history do not increase the risk for adverse effects of phenytoin.

Cognitive Level: Application Text Reference: p. 1538
Nursing Process: Assessment NCLEX: Physiological Integrity

31. A patient is seen in the health clinic with symptoms of a stooped posture, shuffling gait, and pill rolling-type tremor. The nurse will anticipate teaching the patient about
a. preparation for an MRI.
b. purpose of EEG testing.
c. antiparkinsonian drugs.
d. oral corticosteroids.

Correct Answer: C
Rationale: The diagnosis of Parkinson's is made when two of the three characteristic signs of tremor, rigidity, and bradykinesia are present. The confirmation of the diagnosis is made on the basis of improvement when antiparkinsonian drugs are administered. This patient has symptoms of tremor and bradykinesia; the next anticipated step will be treatment with medications. MRI and EEG are not useful in diagnosing Parkinson's disease, and corticosteroid therapy is not used to treat it.

Cognitive Level: Application Text Reference: p. 1550
Nursing Process: Planning NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. When preparing to admit a patient who has been treated for status epilepticus in the emergency department, which equipment should the nurse have available in the room? (Select all that apply.)
a. Suction tubing
b. Oxygen mask
c. Nasogastric tube
d. Siderail pads
e. Tongue blade
f. Oral airway

Correct Answer: A, B, D
Rationale: The patient is at risk for further seizures, and oxygen and suctioning may be needed after any seizures to clear the airway and maximize oxygenation. The bed's side rails should be padded to minimize the risk for patient injury during a seizure. Insertion of a nasogastric (NG) tube is not indicated because the airway problem is not caused by vomiting or abdominal distention. Use of tongue blades or oral airways during a seizure is contraindicated.

Cognitive Level: Application Text Reference: pp. 1539-1540
Nursing Process: Planning NCLEX: Physiological Integrity

2. A patient with Parkinson's disease is admitted to the hospital for treatment of an acute infection. Which nursing interventions will be included in the plan of care? (Select all that apply.)
a. Cut patient's food into small pieces.
b. Provide high protein foods at each meal.
c. Observe for sudden exacerbation of symptoms.
d. Remind the patient to keep eyes ahead when ambulating.
e. Place an arm chair at the patient's bedside.
f. Use an elevated toilet seat.

Correct Answer: A, E, F
Rationale: Since the patient with Parkinson's has difficulty chewing, food should be cut into small pieces. An armchair should be used when the patient is seated so that the patient can use the arms to assist with getting up from the chair. An elevated toilet seat will facilitate getting on and off the toilet. High-protein foods will decrease the effectiveness of L-dopa. Parkinson's is a steadily progressive disease without acute exacerbations. Bradykinesia associated with ambulation is relieved by asking the patient to step over imaginary lines or rice kernels on the floor.

Cognitive Level: Application Text Reference: pp. 1552-1553
Nursing Process: Planning NCLEX: Physiological Integrity

Please allow access to your computer’s microphone to use Voice Recording.

Having trouble? Click here for help.

We can’t access your microphone!

Click the icon above to update your browser permissions above and try again

Example:

Reload the page to try again!

Reload

Press Cmd-0 to reset your zoom

Press Ctrl-0 to reset your zoom

It looks like your browser might be zoomed in or out. Your browser needs to be zoomed to a normal size to record audio.

Please upgrade Flash or install Chrome
to use Voice Recording.

For more help, see our troubleshooting page.

Your microphone is muted

For help fixing this issue, see this FAQ.

Star this term

You can study starred terms together

NEW! Voice Recording

Create Set