Which assessment data would make the nurse suspect that the client has amyotrophic lateral sclerosis?
A nurse is caring for a client in the emergency department….
A nurse is caring for a client in the emergency department. History and Physical 1100: Client presents to emergency department and states, “I have a terrible headache.” Client reports having a headache for the past three days and the pain is getting worse.. Client reports feeling “feverish” and sensitive to lights. Client has taken ibuprofen for pain and ineffective. Client denies confusion or dizziness, although family members question their confusion yesterday. Past medical history is unremarkable. Nurses’ Notes 1100: Nurse to perform assessment on client. Client is squinting eyes to light and nystagmus noted. Rates headache pain as “8” on 0-10 pain scale. Client has nuchal rigidity. Heart regular rhythm and tachycardiac. Lungs sounds are clear to auscultation in all lobes. Client is alert and oriented to person, place and time. 1145: Nurse enters client’s room. Client actively seizing in bed with tonic-clonic characteristics. Placed client on their side. Lorazepam administered, and seizure activity ceased after approximately 1 minute. Provider notified. 1150: Client is lethargic following seizure. Nystagmus noted. Client is tachycardiac. Disoriented to person, place and time. Diagnostics 1130: CT scan: no acute intracranial abnormality, no mass 1230: Lumbar puncture Vital Signs 1100: Temperature 38.3 °C (100.9 °F) Respiratory Rate 19/min Heart Rate 111/min Blood Pressure 129/78 mm Hg 1200: Temperature 38.4 °C (101.1 °F) Respiratory Rate 22/min Heart Rate 115/min Blood Pressure 151/95mm Hg Medication Administration Record 1145: Lorazepam 4 mg IV push What potential condition is the client most likely experiencing ? The nurse should monitor and ?
The personal values of counselors
The personal values of counselors
A client has surgery for the creation of burr holes after su…
A client has surgery for the creation of burr holes after sustaining head trauma from a fall and is at risk for developing meningitis. The nurse assesses for meningeal irritation by having the client lying supine with the leg flexed at the knee and hip. The client is assessed for pain and the ability to straighten the extremity. What is this assessment?
To be effective when counseling clients with physical disabi…
To be effective when counseling clients with physical disabilities, counselors should
The 29-year-old client is admitted to the medical floor diag…
The 29-year-old client is admitted to the medical floor diagnosed with meningitis. Which assessment by the nurse is the priority?
Which non-opioid analgesic produces irreversible inhibition…
Which non-opioid analgesic produces irreversible inhibition of COX enzymes?
Which diabetes agents cause higher risk of UTIs and genital…
Which diabetes agents cause higher risk of UTIs and genital mycotic infections due to their action of increasing excretion of urinary glucose?
In which environment is most respiratory care delivered?
In which environment is most respiratory care delivered?
A patient is being monitored by an ECG during a sleep study….
A patient is being monitored by an ECG during a sleep study. The patient has a heart rate of less than 40 beats/min. You would score the event as: