Question 1 of 5.

Extract:The nurse in the emergency department (ED) is caring for a 26-year-old female client. Item 2 of 6 History and Physical 1702: The client reports a headache that has persisted for 48 hours. She describes the pain as constant, throbbing, and behind her left eye. She states that in the past six months, these headaches have occurred two to three times a month. The client reports visual disturbances, including flashes of light and blurred vision, often precede headaches. During the headache episodes, she experiences nausea, photophobia, and phonophobia. She notes that stress, lack of sleep, and certain foods such as chocolate seem to trigger the headaches. Over-the-counter pain relievers provide minimal relief. Her spouse reports new symptoms, stating that she became confused earlier in the day, had difficulty speaking, and had right arm weakness, all of which resolved before she arrived at the ED. Medical history of generalized anxiety and panic disorder for which she takes escitalopram 20 mg p.o. daily and buspirone 15 mg p.o. daily. Family history of ischemic stroke, hypertension, and diabetes mellitus. Physical Examination Neurological exam: Steady gait and cranial nerves grossly intact. Phonophobia. Pupils: 3 mm and brisk with some tearing in both eyes. Sensitive to pen light. Head and neck examination: Denies sinus pain and full cervical range of motion. Integumentary: Skin warm to touch and pale pink in tone. Cardiovascular: Peripheral pulses 2+ and no peripheral edema. Respiratory: Clear lung sounds bilaterally. Gastrointestinal: Reports persistent nausea. Normoactive bowel sounds in all quadrants. No distention. Psych: Anxious and in moderate distress. Cooperative. Vital Signs: Blood pressure: 120/80 mmHg Heart rate: 72 bpm Respiratory rate: 16 Temperature: 98.6°F (37°C) Oxygen saturation: 98% on room air

The nurse recognizes that which of the following conditions may feature photophobia? Select all that apply.

Question 2 of 5.

Extract:The following scenario applies to the next 1 items The nurse in the emergency department is caring for a 22-year-old female. Item 1 of 1 History And Physical Orders 1114: A 22-year-old female client was with friends at a restaurant and reportedly started acting odd and then had uncontrollable and uncoordinated movements. This lasted three minutes. Once this terminated, EMS was called, and this occurred again and lasted four minutes. EMS administered lorazepam. The client does not have any medical history or take any medications. On exam, she did not recall the seizure, nor did she remember how she felt leading up to the seizure. She denied any drug use. She is drowsy following the administration of lorazepam but can sustain attention and is fully oriented. Glasgow Coma Scale 14. Will admit the client for observation.

For each physician order, click to specify the appropriate nursing intervention: Magnetic Resonance Imaging (MRI) of the brain

Question 3 of 5.

The nurse is caring for a client who is experiencing status epilepticus. Which of the following actions should be prioritized by the nurse?

Question 4 of 5.

The nurse is assessing a client with suspected Cushing's triad. Which of the following findings would support a diagnosis of Cushing's triad?

Question 5 of 5.

The nurse is teaching a client newly diagnosed with multiple sclerosis. Which of the following statements by the client would indicate a correct understanding of the teaching?