A nursing student is teaching a patient and family about epilepsy prior to the patient’s discharge. For which statement should you intervene?
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Solution
Set up oxygen and suction equipment.
Option B: The LPN/LVN can set up the equipment for oxygen and suctioning.
Option A: The RN should perform the complete initial assessment.
Option C: Padded side rails are controversial in terms of whether they actually provide safety and ay embarrass the patient and family. Tongue blades should not be at the bedside and should never be inserted into the patient’s mouth after a seizure begins. Focus: Delegation/supervision.
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?
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Solution
Take the patient’s vital signs.
Option C: Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision
The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?
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Solution
Take the patient’s vital signs.
Option C: Taking vital signs is within the education and scope of practice for a nursing assistant. The nurse should perform neurologic checks and document the seizure. Patients with seizures should not be restrained; however, the nurse may guide the patient’s movements as necessary. Focus: Delegation/supervision
You are creating a teaching plan for a patient with newly diagnosed migraine headaches. Which key items should be included in the teaching plan? (Choose all that apply).
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Solution
Answers: A, B, C, D, and E
Option F: Medications such as estrogen supplements may actually trigger a migraine headache attack.
Options A, B, C, D, and E: All of the other statements are accurate. Focus: Prioritization
What is the priority nursing diagnosis for a patient experiencing a migraine headache dd?
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Solution
Acute pain related to biologic and chemical factors
Option A: The priority for interdisciplinary care for the patient experiencing a migraine headache is pain management.
Options B, C, and D: All of the other nursing diagnoses are accurate, but none of them is as urgent as the issue of pain, which is often incapacitating. Focus: Prioritization
Which of the following classes of drugs is most widely used in the treatment of cardiomyopathy?
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Solution
Beta-adrenergic blockers
Option B: By decreasing the heart rate and contractility, beta-adrenergic blockers improve myocardial filling and cardiac output, which are primary goals in the treatment of cardiomyopathy.
Option A: Antihypertensives aren’t usually indicated because they would decrease cardiac output in clients who are often already hypotensive.
Option C: Calcium channel blockers are sometimes used for the same reasons as beta-adrenergic blockers; however, they aren’t as effective as beta-adrenergic blockers and cause increase hypotension.
Option D: Nitrates aren’t’ used because of their dilating effects, which would further compromise the myocardium.
Which of the following cardiac conditions does a fourth heart sound (S4) indicate?
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Solution
Failure of the ventricle to eject all the blood during systole
Option D: An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. This increased resistance is related to decrease compliance of the ventricle.
Option A: A dilated aorta doesn’t cause an extra heart sound, though it does cause a murmur.
Option C: Decreased myocardial contractility is heard as a third heart sound.
Option B: An s4 isn’t heard in a normally functioning heart.
Which of the following types of cardiomyopathy does not affect cardiac output?
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Solution
Hypertrophic
Option B: Cardiac output isn’t affected by hypertrophic cardiomyopathy because the size of the ventricle remains relatively unchanged.
Options A and C: Dilated cardiomyopathy and restrictive cardiomyopathy all decrease cardiac output.
Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?
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Solution
Restrictive
Option D: These are the classic symptoms of heart failure.
Option A: Pericarditis is exhibited by a feeling of fullness in the chest and auscultation of a pericardial friction rub.
Option B: Hypertension is usually exhibited by headaches, visual disturbances, and a flushed face. Myocardial infarction causes heart failure but isn’t related to these symptoms.
What is the term used to describe an enlargement of the heart muscle?
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Solution
Cardiomegaly
Option A: Cardiomegaly denotes an enlarged heart muscle.
Option B: Cardiomyopathy is a heart muscle disease of unknown origin.
Option C: Myocarditis refers to inflammation of heart muscle.
Option D: Pericarditis is an inflammation of the pericardium, the sac surrounding the heart.