chapter 61 Flashcards
The nurse is teaching a client about management of migraine headaches. Which of the
following client statements indicates that the teaching has been effective?
a. “I will take the topiramate as soon as any headaches start.”
b. “I should avoid taking Aspirin and sumatriptan at the same time.”
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.”
C
It is recommended that the client with a migraine rest in a dark, quiet area. Topiramate is
used to prevent migraines and must be taken for several months to determine effectiveness.
Aspirin or other nonsteroidal anti-inflammatory medications can be taken with the triptans.
Alcohol may precipitate migraine headaches.
Which of the following parameters should the nurse assess when caring for a client who is
experiencing a cluster headache?
a. Nuchal rigidity
b. Projectile vomiting
c. Unilateral eyelid swelling
d. Throbbing, bilateral facial pain
C
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.
A client has a tonic–clonic seizure while the nurse is in the client’s room. Which of the
following actions should the nurse take?
a. Insert an oral airway during the seizure to maintain a patent airway.
b. Restrain the client’s arms and legs to prevent injury during the seizure.
c. Avoid touching the client to prevent further nervous system stimulation.
d. Time and observe and record the details of the seizure and postictal state.
D
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 client during the seizure are contraindicated. The nurse may
need to move the client to decrease the risk of injury during the seizure.
An elementary teacher who has just been diagnosed with epilepsy after having a
generalized tonic–clonic seizure tells the nurse, “I cannot teach anymore, it will be too
upsetting if I have a seizure at work.” Which of the following responses by the nurse is
best?
a. “You may want to contact the Epilepsy Foundation for assistance.”
b. “You might benefit from some psychological counselling at this time.”
c. “The Department of Vocational Rehabilitation can help with work retraining.”
d. “Half of all clients with epilepsy are well controlled with antiseizure drugs.”
D
The nurse should inform the client that about 50% clients with seizure disorders are
controlled with medication and another 30% have a decrease in the intensity and
frequency of seizures. The other information may be necessary if the client seizures persist
after treatment with antiseizure drugs is implemented.
Which action will the nurse take when evaluating a client who is taking phenytoin for
adverse effects of the medication?
a. Inspect the oral mucosa.
b. Listen to the lung sounds.
c. Auscultate the bowel tones.
d. Check pupil reaction to light.
A
Phenytoin can cause gingival hyperplasia, but does not affect bowel tones, lung sounds, or
pupil reaction to light.
A client found in a tonic–clonic seizure reports afterward that the seizure was preceded by
numbness and tingling of the arm. Which of the following types of seizures should the
nurse document based upon this finding?
a. Atonic
b. Partial
c. Absence
d. Myoclonic
B
The initial symptoms of a partial seizure involve clinical manifestations that are localized
to a particular part of the body or brain. Symptoms of an absence seizure are staring and a
brief loss of consciousness. In an atonic seizure, the client loses muscle tone and (typically)
falls to the ground. Myoclonic seizures are characterized by a sudden jerk of the body or
extremities.
The nurse is obtaining a health history and physical assessment from a client with possible
multiple sclerosis (MS). Which of the following assessments should the nurse include?
a. Assess for the presence of chest pain.
b. Inquire about any urinary tract problems.
c. Inspect the skin for rashes or discoloration.
d. Question the client about any increase in libido.
B
Urinary tract problems with incontinence or retention are common symptoms of MS.
Chest pain and skin rashes are not symptoms of MS. A decrease in libido is common with
MS.
A female client who has multiple sclerosis (MS) asks the nurse about risks associated with
pregnancy. Which of the following responses by the nurse is accurate?
a. “MS symptoms may be worse after the pregnancy.”
b. “Women with MS frequently have premature labour.”
c. “Symptoms of MS are likely to become worse during pregnancy.”
d. “MS is associated with a slightly increased risk for congenital defects.”
A
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. Onset of labour is not
affected by MS.
The nurse is caring for a client with multiple sclerosis (MS) who is to begin treatment with
glatiramer acetate. Which of the following information should the nurse include in client
teaching?
a. Recommendation to drink at least 3–4 L of water 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
C
Copaxone is administered by self-injection. Oral contraceptives are an appropriate choice
for birth control. There is no need to avoid driving or drink large fluid volumes when
taking glatiramer.
The nurse is caring for a client with epilepsy. Which of the following laboratory results
should the nurse expect?
a. Increased blood glucose
b. Decreased BUN
c. Increased creatinine
d. Decreased liver function tests
C
The blood work results of a client with epilepsy would show an increased creatinine level.
The other results that would be expected are a decreased blood glucose level, increased
BUN, and increased liver function tests.
The nurse is caring for a client with multiple sclerosis (MS) who has urinary retention
caused by a flaccid bladder. Which of the following actions should the nurse plan to take?
a. Teach the client how to perform self-catheterization.
b. Decrease the client’s fluid intake in the evening.
c. Suggest the use of incontinence briefs for nighttime use only.
d. Assist the client to the commode every 2 hours during the day.
A
Bladder control is a major problem for many patients with MS. Although anticholinergics
may be beneficial for some patients to decrease spasticity, other patients may need to be
taught self-catheterization. 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.
A client with Parkinson’s disease has a nursing diagnosis of impaired physical mobility
related to bradykinesia. Which of the following actions should the nurse include in the
plan of care?
a. Instruct the client in activities that can be done while lying or sitting.
b. Suggest that the client rock from side to side to initiate leg movement.
c. Have the client take small steps in a straight line directly in front of the feet.
d. Teach the client to keep the feet in contact with the floor and slide them forward.
B
Rocking the body from side to side stimulates balance and improves mobility. The client
will be encouraged to continue exercising because this will maintain functional abilities.
Maintaining a wide base of support will help with balance. The client should lift the feet
and avoid a shuffling gait.
A client has a new prescription for bromocriptine mesylate to control symptoms of
Parkinson’s disease. Which of the following information obtained by the nurse may
indicate a need for a decrease in the dose?
a. The client has a chronic dry cough.
b. The client has four loose stools in a day.
c. The client develops a deep vein thrombosis.
d. The client’s blood pressure is 90/46 mm Hg.
D
Hypotension is an adverse effect of bromocriptine mesylate, and the nurse should check
with the health care provider before giving the medication. Diarrhea, cough, and deep vein
thrombosis are not associated with bromocriptine mesylate use.
The nurse is providing teaching to a client with myasthenia gravis (MG) about
management of the disease? Which of the following information should the nurse include
in the teaching plan?
a. Perform physically demanding activities in the morning.
b. Anticipate the need for weekly plasmapheresis treatments.
c. Do frequent weight-bearing exercise to prevent muscle atrophy.
d. Protect the extremities from injury due to poor sensory perception.
A
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 situations in which 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.
The nurse is assessing a client in the outpatient clinic who has restless legs syndrome.
Which of the following over-the-counter medications that the client is taking routinely
should the nurse discuss with the client?
a. Multivitamin
b. Acetaminophen
c. Ibuprofen
d. Diphenhydramine
D
Antihistamines can aggravate restless legs syndrome. The other medications will not
contribute to the restless legs syndrome.
