A client is taking the prescribed dose of phenytoin to control seizures. Results of a phenytoin blood level study reveal a level of 35 mcg/mL (140mcmol/L). Which finding would be expected as a result of this laboratory result?

Carbamazepine (Tegretol) is prescribed for a client in the management of generalized tonic-clonic seizures. The nurse is providing instructions to the client regarding the side and adverse effects of the medication and tells the client to inform the health care provider if which occurs?

The nurse is in the room with a client when a seizure begins. The client’s entire body becomes rigid, and the muscles in all four extremities alternate between relaxation and contraction. Following the seizure, which type of seizure should the nurse document that the client had experienced?

A client begins to experience a tonic-clonic seizure. Which actions should the nurse take? Select all that apply. 1. Restrain the client. 2. Turn the client to the side. 3. Maintain the client’s airway. 4. Place a padded tongue blade into the client’s mouth. 5. Loosen any restrictive clothing that the client is wearing. 6. Protect the client from injury, and guide the client’s movements.

The nurse receives a telephone call from the emergency department and is told that a child with a diagnosis of tonic-clonic seizures will be admitted to the pediatric unit. The nurse prepares for the admission of the child and instructs the unlicensed assistive personnel to place which items at the bedside?

The nurse is preparing a plan regarding home care instructions for the parents of a child with generalized tonic-clonic seizures who is being treated with oral phenytoin (Dilantin). Which instruction should the nurse include in the plan?

The nurse is reviewing the results of a client’s phenytoin (Dilantin) level that was drawn that morning. What result indicates the client has reached a therapeutic drug level? 1. 3 mcg/mL 2. 8 mcg/mL 3. 15 mcg/mL 4. 24 mcg/mL

The nurse is planning care for a client with a T3 spinal cord injury. The nurse should include which intervention in the plan to prevent autonomic dysreflexia (hyperreflexia)? 1. Assist the client to develop a daily bowel routine to prevent constipation. 2. Teach the client that this condition is relatively minor with few symptoms. 3. Assess vital signs and observe for hypotension, tachycardia, and tachypnea. 4. Administer dexamethasone (Decadron) per the health care provider’s prescription.

The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care? 1. Change the client’s positions slowly. 2. Assess the client for decreased sensation to touch. 3. Assess the client for decreased sensation to vibration. 4. Teach the client about loss of motor function and decreased pain sensation.

The nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care plan, the nurse monitors for spinal shock. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed? 1. Dextran 2. 0.9% normal saline 3. 5% dextrose in water 4. 5% dextrose in 0.9% normal saline

The nurse is caring for a client with a spinal cord injury who is in spinal shock. The nurse performs an assessment on the client, knowing that which assessment will provide the best information about recovery from spinal shock? 1. Reflexes 2. Pulse rate 3. Temperature 4. Blood pressure

A client with a spinal cord injury is at risk of developing footdrop. What should the nurse use as the effective preventive measure? 1. Foot board 2. Heel protectors 3. Posterior splints 4. Pneumatic boots

A client is being brought into the emergency department after suffering a head injury. Which should the nurse assess first? 1. Level of consciousness 2. Pulse and blood pressure 3. Respiratory rate and depth 4. Ability to move extremities

The nurse is caring for a client with a C-6 spinal cord injury during the spinal shock phase. What should the nurse implement when preparing the client to sit in a chair? 1. Apply knee splints to stabilize the joints during transfer 2. Teach the client to lock the knees during the pivoting stage of the transfer 3. Administer a vasodilator in order to improve circulation of the lower limbs 4. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes

The nurse is planning a discharge teaching plan for a client with a spinal cord injury. To provide for a safe environment regarding home care, which option should be the priority in the discharge teaching plan? 1. Assisting the client to deal with long-term care placement 2. Including the client’s significant others in the teaching session 3. Follow-up laboratory and diagnostic tests that need to be done 4. What the health care provider has indicated needs to be taught

he nurse has implemented a plan of care for a client with a cervical 5 (C5) spinal cord injury to promote health maintenance. Which client outcome would indicate the effectiveness of the plan? 1. Maintenance of intact skin 2. Regaining of bladder and bowel control 3. Performance of activities of daily living independently 4. Independent transfer of self to and from the wheelchair

A client who sustained a thoracic cord injury a year ago returns to the clinic for a follow-up visit, and the nurse notes a small reddened area on the coccyx. The client is not aware of the reddened area. After counseling the client to relieve pressure on the area by adhering to a turning schedule, which action by the nurse is most appropriate? 1. Teaching the client to feel for reddened areas 2. Asking a family member to assess the skin daily 3. Teaching the client to use a mirror for skin assessment 4. Scheduling the client to return to the clinic daily for a skin check

When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem? 1. “Avoid caffeine in your diet.” 2. “Take your temperature every day.” 3. “Limit your fluid intake to 1000 mL per 24 hours.” 4. “Catheterize yourself every 2 hours as needed to prevent spasm.”

The nurse teaches a client with a spinal cord injury about measures to prevent autonomic hyperreflexia. Which statement by the client would indicate the need for additional teaching? 1. “It is best if I avoid tight clothing and lumpy bedclothes.” 2. “I should watch for headache, congestion, and flushed skin.” 3. “Symptoms I should watch for include fever and chest pain.” 4. “I need to pay close attention to how frequently my bowels move.”

he nurse is discharging a female client from the hospital who has a diagnosis of a thoracic 11 (T11) fracture with cord transection. The nurse has provided home care instructions to the client. Which action would indicate the need for further teaching before discharge? 1. The client jokes about no longer needing to worry about birth control. 2. The client states that she will be careful to not eat as many dairy products. 3. The client verbalizes the need to eat her meals at the same time every day. 4. The client states that she will wash her hands, her perineum, and the catheter with soap and water before performing self-catheterization.

The nurse is caring for a client who is recovering from an episode of autonomic hyperreflexia. Which therapeutic statement should the nurse make to the client? 1. “How could your home care nurse let this happen?” 2. “Now that this problem is taken care of, I’m sure you’ll be fine.” 3. “I have some time if you would like to talk about what happened to you.” 4. “I’m sure you now understand the importance of preventing this from occurring.”

While assisting a client with a spinal cord injury with activities of daily living, the client states, “I can’t do this. I wish I were dead.” Which therapeutic response should the nurse make to the client? 1. “Why do you say that?” 2. “You wish you were dead?” 3. “Let’s wash your back now.” 4. “I’m sure you are frustrated, but things will work out just fine for you.”

Which statement made by a client with a spinal cord injury warrants follow-up by the nurse? 1. “I’m so angry that this happened to me.” 2. “I’m really looking forward to going home.” 3. “I know I will have to make major adjustments in my life.” 4. “I would like my family members to be here for my teaching sessions.”

A young adult client with a spinal cord injury tells the nurse, “It’s so depressing that I’ll never get to have sex again.” What is the realistic reply for the nurse to make to the client? 1. “It must feel horrible to know you can never have sex again.” 2. “It’s still possible to have a sexual relationship, but it will be different.” 3. “You’re young, so you’ll adapt to this more easily than if you were older.” 4. “Because of body reflexes, sexual functioning will be no different than before.”

A client with a T1 spinal cord injury has just learned that the cord was completely severed. The client says, “I’m no good to anyone. I might as well be dead.” Which response should the nurse make to the client? 1. “You’re not a useless person at all.” 2. “I’ll ask the psychologist to see you about this.” 3. “You are feeling pretty bad about things right now.” 4. “It makes me uncomfortable when you talk this way.”

A client with a recent complete T4 spinal cord transection tells the nurse that he will walk again as soon as the spinal shock resolves. Which statement provides the most accurate basis for planning a response to the client? 1. The client is projecting by insisting that walking is the rehabilitation goal. 2. To speed acceptance, the client needs reinforcement that he will not walk again. 3. Denial can be protective while the client deals with the anxiety created by the new disability. 4. The client needs to move through the grieving process rapidly to benefit from rehabilitation.

The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving? Select all that apply. 1. Flaccidity 2. Presence of a gag reflex 3. Positive Babinski’s reflex 4. Development of hyperreflexia 5. Return of the bulbocavernous reflex 6. Return of reflex emptying of the bladder

The nurse is caring for a client with a head injury and is monitoring the client for decerebrate posturing. Which is characteristic of this type of posturing? 1. Abnormal involuntary flexion of the extremities 2. Abnormal involuntary extension of the extremities 3. Upper extremity extension with lower extremity flexion 4. Upper extremity flexion with lower extremity extension

The nurse is caring for a client admitted to the hospital after sustaining a head injury. In which position should the nurse place the client to prevent increased intracranial pressure (ICP)? 1. In left Sims’ position 2. In reverse Trendelenburg 3. With the head elevated on a pillow 4. With the head of the bed elevated at least 30 degrees

A client was admitted to the nursing unit with a closed head injury 6 hours ago. During initial assessment, the nurse finds that the client has vomited, is confused, and complains of dizziness and headache. Based on these data, which is the most important nursing action? 1. Administer an antiemetic. 2. Notify the health care provider. 3. Reorient the client to surroundings. 4. Change the client’s gown and bed linens.

A client is being brought into the emergency department after suffering a head injury. Which should the nurse assess first? 1. Level of consciousness 2. Pulse and blood pressure 3. Respiratory rate and depth 4. Ability to move extremities

The nurse is planning discharge teaching for the parents of a child who sustained a head injury and who is now receiving tapering doses of dexamethasone. The nurse plans to make which statement to the parents? 1. “This medication decreases the chance of infection.” 2. “This medication will be discontinued after two doses.” 3. “If your child’s face becomes puffy, the medication dose needs to be increased.” 4. “This medication is tapered to decrease the chance of recurring swelling in the brain.”

A client recovering from a head injury becomes agitated at times. Which action should the nurse incorporate to calm this client? 1. Assign the client a new task to master. 2. Turn on the television to a musical program. 3. Make the client aware that the behavior is undesirable. 4. Talk to the client about the familiar objects, such as family pictures, that are kept in the client’s room.

The nurse is interacting with the family of a client who is unconscious as a result of a head injury. Which approach should the nurse use to help the family cope with this situation? 1. Explain equipment and procedures on an ongoing basis. 2. Discourage displays of grief so the client isn’t saddened. 3. Encourage the use of limited touch to allow the client to rest. 4. Explain that the client must rest so they must adhere to regular visiting hours.

A client with a head injury and a feeding tube continuously tries to remove the tube. The nurse contacts the health care provider who prescribes the use of restraints. After checking the agency’s policy and procedure regarding the use of restraints, the nurse uses which method in restraining the client? 1. Belt restraint 2. Waist restraint 3. Wrist restraints 4. Mitten restraints

The nurse is monitoring a nursing student who is caring for a child who sustained a head injury from a fall. Which action by the nursing student indicates a need for further teaching? 1. Forcing fluids 2. Performing neurological assessments 3. Keeping the child in a sitting-up position 4. Keeping the child awake as much as possible

The nurse is caring for a client with an acute head injury. Which neurological sign should the nurse carefully assess as the primary indicator of neurological status? 1. Vital signs 2. Motor function 3. Sensory function 4. Level of consciousness

A prenatal client has been told during a health care provider office visit that she is positive for human immunodeficiency virus (HIV). The client cried and was significantly distressed regarding this news. Which client problem statement would this assessment data best support? 1 . Pain. 2. Non-Adherence. 3. Anticapatory Greiving . 4. High Risk for Infection.

A client has an initial positive result of an enzyme-linked immunosorbent assay (ELISA) test for human immunodeficiency virus (HIV). The client begins to cry and asks the nurse what this means. What knowledge should the nurse use to provide support to the client? 1. The client is HIV positive, but the client’s CD4 cell count is high. 2. The client is HIV positive, but the disease has been detected early. 3. There are occasional false-positive readings with this test, which can be cleared up by repeating it one more time. 4. False-positive results can occur, and more testing is needed before diagnosing the client as being HIV positive.

A client diagnosed with acquired immunodeficiency syndrome (AIDS) is reporting fatigue. Which strategy should the nurse teach the client to conserve energy after discharge from the hospital? 1. Bathe before eating breakfast. 2. Sit for as many activities as possible. 3. Stand in the shower instead of taking a bath. 4. Group all tasks to be performed early in the morning

The nurse is caring for a client diagnosed with acquired immunodeficiency syndrome (AIDS). Which sign/symptom indicates the presence of an opportunistic respiratory infection? 1. Nausea and vomiting 2. Fever and exertional dyspnea 3. An arterial blood gas pH of 7.40 4. A respiratory rate of 20 breaths per minute

The nurse is developing a plan of care for a client with acquired immunodeficiency syndrome (AIDS). The nurse should document which appropriate goal in the plan of care? 1. The client has no increased platelet aggregation. 2. The client has a urinary output of 50 mL per hour. 3. The client does not experience respiratory distress. 4. The client has no evidence of a dissecting aortic aneurysm.

A client with acquired immunodeficiency syndrome who has cytomegalovirus retinitis is receiving ganciclovir (Cytovene). Which action should the nurse plan to take while the client is taking this medication? 1. Monitor blood glucose levels for elevation. 2. Administer the medication on an empty stomach only. 3. Apply pressure to venipuncture sites for at least 2 minutes. 4. Provide the client with a soft toothbrush and an electric razor.

A client with a diagnosis of trigeminal neuralgia is started on a regimen of carbamazepine (Tegretol). The nurse provides instructions to the client about the medication. What statement by the client indicates that the client understands the instructions? 1. “I will report a fever or sore throat to my doctor.” 2. “Some joint pain is expected and is nothing to worry about.” 3. “I must brush my teeth frequently to avoid damage to my gums.” 4. “My urine may turn red in color, but this is nothing to be concerned about.”

The home care nurse is evaluating a client’s understanding of the self-management of trigeminal neuralgia. Which client statement indicates that there is a need for further teaching? 1. “I should chew on my good side.” 2. “An analgesic will relieve my pain.” 3. “I should use warm mouthwash for oral hygiene.” 4. “Taking my carbamazepine (Tegretol) will help control my pain.”

The nurse is preparing to assess a client who was admitted to the hospital with a diagnosis of trigeminal neuralgia (tic douloureux). On review of the client’s record, which symptom should the nurse expect to note that the client is experiencing? 1. Bilateral pain in the area of the sixth cranial nerve 2. Unilateral pain in the area of the sixth cranial nerve 3. Abrupt onset of pain in the area of the fifth cranial nerve 4. Chronic, intermittent pain in the area of the seventh cranial nerve

A client with trigeminal neuralgia asks the nurse what can be done to minimize the episodes of pain. The nurse’s response is based on an understanding that what can trigger the pain? 1. Infection or stress 2. Hypoglycemia and fatigue 3. Facial pressure or extreme temperature 4. Excessive watering of the eyes or nasal stuffiness

A client with trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client? 1. Hot cocoa with honey and toast 2. Vanilla pudding and lukewarm milk 3. Hot herbal tea with graham crackers 4. Iced coffee and peanut butter and crackers

The nurse makes a home care visit to a client with Bell’s palsy. Which statement by the client indicates a need for further teaching? 1. “I wear an eye patch at night.” 2. “I am staying on a liquid diet.” 3. “I wear dark glasses when I go out.” 4. “I have been gently massaging my face.”

The nurse is caring for a client with left-sided Bell’s palsy. Which statement by the client requires follow-up by the nurse? 1. “My left eye is tearing a lot.” 2. “I have trouble closing my left eyelid.” 3. “I can’t taste anything on the left side.” 4. “I don’t know how I’ll live with this stroke.”

A client with Bell’s palsy is distressed about the change in facial appearance. Which characteristic of Bell’s palsy should the nurse tell the client about to help the client cope with the disorder? 1. It usually resolves when treated with vasodilator medications. 2. It is similar to stroke, but all symptoms will go away eventually. 3. It is not caused by stroke, and many clients recover in 3 to 5 weeks. 4. The symptoms will completely go away once the tumor is removed.

A client has been diagnosed with Bell’s palsy. The nurse assesses the client to determine if which signs/symptoms are present? 1. Eye paralysis and ptosis of the eyelids 2. Chewing difficulties and one-sided facial droop 3. Fixed pupil and an elevated eyelid on one side 4. Twitching of one side of the face and ruddy cheeks