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1. What is the priority nursing diagnosis for a patient experiencing a migraine headache?

Acute pain related to biologic and chemical factors

Anxiety related to change in or threat to health status

Hopelessness related to deteriorating physiological condition

Risk for Side effects related to medical therapy

Question 1 xplanation!

"he priority for interdisciplinary care for the patient experiencing a migraine headache is pain management.

All of the other nursing diagnoses are accurate# but none of them is as urgent as the issue of pain# $hich is

often incapacitating. %ocus! &rioriti'ation

(. )ou are creating a teaching plan for a patient $ith ne$ly diagnosed migraine headaches. Which key items

should be included in the teaching plan? *+hoose all that apply,.

A-oid foods that contain tyramine# such as alcohol and aged cheese.

A-oid drugs such as "agamet# nitroglycerin and ifedipine.

Aborti-e therapy is aimed at eliminating the pain during the aura.

A potential side effect of medications is rebound headache.

+omplementary therapies such as relaxation may be helpful.

+ontinue taking estrogen as prescribed by your physician.

Question ( xplanation!

/edications such as estrogen supplements may actually trigger a migraine headache attack. All of the otherstatements are accurate. %ocus! &rioriti'ation

0. "he patient $ith migraine headaches has a sei'ure. After the sei'ure# $hich action can you delegate to the

nursing assistant?

ocument the sei'ure.

&erform neurologic checks.

"ake the patient2s -ital signs.

Restrain the patient for protection.

Question 0 xplanation!

"aking -ital signs is $ithin the education and scope of practice for a nursing assistant. "he nurse should

perform neurologic checks and document the sei'ure. &atients $ith sei'ures should not be restrained3

ho$e-er# the nurse may guide the patient2s mo-ements as necessary. %ocus! elegation4super-ision

5. )ou are preparing to admit a patient $ith a sei'ure disorder. Which of the follo$ing actions can you

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delegate to 6&467?

+omplete admission assessment.

Set up oxygen and suction e8uipment.

&lace a padded tongue blade at bedside.

&ad the side rails before patient arri-es.

Question 5 xplanation!

"he 6&467 can set up the e8uipment for oxygen and suctioning. "he R should perform the complete

initial assessment. &added side rails are contro-ersial in terms of $hether they actually pro-ide safety and ay

embarrass the patient and family. "ongue blades should not be at the bedside and should ne-er be inserted

into the patient2s mouth after a sei'ure begins. %ocus! elegation4super-ision.

9. A nursing student is teaching a patient and family about epilepsy prior to the patient2s discharge. %or $hich

statement should you inter-ene?:)ou should a-oid consumption of all forms of alcohol.;

:Wear your medical alert bracelet at all times.;

:&rotect your lo-ed one2s air$ay during a sei'ure.;

: to take o-erthecounter medications.;

Question 9 xplanation!

A patient $ith a sei'ure disorder should not take o-erthecounter medications $ithout consulting $ith the

physician first. "he other three statements are appropriate teaching points for patients $ith sei'ures disorders

and their families. %ocus! elegation4super-ision

@. A patient $ith &arkinson2s disease has a nursing diagnosis of

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maintaining independence. %ocus! elegation4super-ision

. "he nurse is preparing to discharge a patient $ith chronic lo$ back pain. Which statement by the patient

indicates that additional teaching is necessary?

:< $ill a-oid exercise because the pain gets $orse.;

:< $ill use heat or ice to help control the pain.;

:< $ill not $ear highheeled shoes at home or $ork.;

:< $ill purchase a firm mattress to replace my old one.;

Question xplanation!

xercises are used to strengthen the back# relie-e pressure on compressed ner-es and protect the back from

reinBury.

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A 95yearold patient $ith &arkinson2s $ho needs assistance $ith bathing

Question D xplanation!

"he ne$ graduate R $ho is oriented to the unit should be assigned stable# noncomplex patients# such as the

patient $ith stroke. "he patient $ith &arkinson2s disease needs assistance $ith bathing# $hich is best

delegated to the nursing assistant. "he patient being transferred to the nursing home and the ne$ly admitted

S+< should be assigned to experienced nurses. %ocus! Assignment

1E. A patient $ith a spinal cord inBury at le-el +05 is being cared for in the . What is the priority

assessment?

etermine the le-el at $hich the patient has intact sensation.

Assess the le-el at $hich the patient has retained mobility.

+heck blood pressure and pulse for signs of spinal shock.

/onitor respiratory effort and oxygen saturation le-el.Question 1E xplanation!

"he first priority for the patient $ith an S+< is assessing respiratory patterns and ensuring an ade8uate

air$ay. "he patient $ith a high cer-ical inBury is at risk for respiratory compromise because the spinal ner-es

*+0 F 9, inner-ate the phrenic ner-e# $hich controls the diaphragm. "he other assessments are also

necessary# but not as high priority. %ocus! &rioriti'ation

11. )ou are pulled from the to the neurologic floor. Which action should you delegate to the nursing

assistant $hen pro-iding nursing care for a patient $ith S+

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Stroke the patient2s inner thigh.

&ull on the patient2s pubic hair.

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to the patient $ith S+

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reported to the nurse# but they are not lifethreatening. %ocus! &rioriti'ation# delegation4super-ision

1C. "he nursing assistant reports to you# the R# that the patient $ith myasthenia gra-is */, has an ele-ated

temperature *1E(.(E %,# heart rate of 1(E4minute# rise in blood pressure *19C4D5,# and $as incontinent off

urine and stool. What is your best first action at this time?

Administer an acetaminophen suppository.

otify the physician immediately.

Recheck -ital signs in 1 hour.

Reschedule patient2s physical therapy.

Question 1C xplanation!

"he changes that the nursing assistant is reporting are characteristics of myasthenia crisis# $hich often

follo$s some type of infection. "he patient is at risk for inade8uate respiratory function.

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"he student mo-es the patient2s tray to the right side of her o-erbed tray.

"he student assists the patient $ith passi-e rangeofmotion *R=/, exercises.

"he student combs the left side of the patient2s hair $hen the patient combs only the right

side.

Question (E xplanation!

&atients $ith right cerebral hemisphere stroke often present $ith neglect syndrome. "hey lean to the left and

$hen asked# respond that they belie-e they are sitting up straight. "hey often neglect the left side of their

bodies and ignore food on the left side of their food trays. "he nurse $ould need to remind the student of this

phenomenon and discuss the appropriate inter-entions. %ocus! elegation4super-ision