SOLVED QUESTION SET GRADED A+
◉1.A client is diagnosed with a headache from a secondary cause.
The nurse realizes this type of headache can be caused by:
1. a tumor.
2. tension.
3. a migraine.
4. cluster. Answer: ANS: 1
Primary headaches are identified when no organic cause can be
found. A tumor headache is caused by a tumor and is classified as a
secondary headache.
◉2.The nurse should instruct a client diagnosed with migraine
headaches to be careful not to overdose on acetaminophen
(Tylenol). Which drug should the nurse tell the patient to avoid?
1. Aleve
2. Aspirin
3. Ibuprofen
4. Vicodin. Answer: ANS: 4
,Vicodin, although a narcotic analgesic, also contains acetaminophen
(Tylenol). It is very easy to overdose on the acetaminophen
(Tylenol) component, which can lead to kidney damage. Aleve does
not contain acetaminophen (Tylenol). Aspirin and ibuprofen do not
contain acetaminophen (Tylenol).
◉3.A client is diagnosed with seizures occurring because of hepatic
encephalopathy. The nurse realizes that the cause for this clients
seizures would be:
1. physiological.
2. iatrogenic.
3. idiopathic.
4. psychokinetic.. Answer: ANS: 1
The three major causes for seizures are physiological, iatrogenic,
and idiopathic. Physiological seizures include those that occur with
an acquired metabolic disorder such as hepatic encephalopathy.
Iatrogenic causes include new medications or drug or alcohol use.
Idiopathic causes include fevers, fatigue, or strong emotions.
Psychokinetic is not a cause for seizures.
◉4.A client tells the nurse that he sees flashing lights that occur
prior to the onset of a seizure. Which of the following phases of a
seizure is this client describing to the nurse?
1. Prodromal phase
2. Aural phase
, 3. Ictal phase
4. Postictal phase. Answer: ANS: 2
In the aural phase a sensation or warning occurs, which the patient
often remembers. This warning can be visual, auditory, gustatory, or
visceral in nature. The prodromal phase of a seizure includes the
signs or activity before the seizure such as a headache or feeling
depressed. The ictal phase of a seizure is the actual seizure. The
postictal phase is the period immediately following the seizure.
◉5.A client is experiencing a grand mal seizure. Which of the
following should the nurse do during this seizure?
1. Protect the clients head.
2. Leave the client alone.
3. Give water to the client to avoid dehydration.
4. Place a finger in the clients mouth to avoid swallowing the
tongue.. Answer: ANS: 1
One of the most important interventions for a nurse to perform
during a seizure is to protect the clients head from injury. Never give
a client a drink during a seizure. Placing a finger in the clients mouth
could be very dangerous to the client and the nurse. Do not leave the
client unattended during a seizure
◉6.A client is prescribed phenytoin (Dilantin) for a seizure disorder.
Which of the following would indicate that the client is adhering to
the medication schedule?