On assessment the LPN/LVN notes flexion of the client’s arms and elbows with the hands raised to the chest and extension of the legs. What term should the nurse use to document this posturing? 

A 64-year-old client was diagnosed with high cholesterol levels 4 months ago. Today he presents to the primary healthcare provider with a new report of frequent headaches. As part of the history and client assessment, the nurse asks the client about current medications he is taking. The client provides incomplete information. Choose the most likely options for the information missing from the table by selecting from the lists of provided options. Write your answer in each corresponding blank box below. 

You are the nurse caring for a client with a history of seizures. The client is managed on the medication carbamazepine.  At the client’s appointment, he reports one seizure in the last month, so the primary healthcare provider ordered a carbamazepine level to be checked.  The level comes back at 3 mcg/mL.  Which of the following is most likely?

The nurse is assessing a client who just had a tonic-clonic seizure. Which finding indicates a need for immediate nursing intervention?

A client is diagnosed with cluster headaches and advised to take naproxen by the health care provider.  What should the nurse educate the client to watch for?

A stroke client with dysphagia is prescribed a soft diet with nectar thick liquids. Which item should the client be instructed to avoid?

The LPN/LVN is assessing a client’s level of consciousness. Based on the following assessment data/scenario what Glasgow Coma Scale score should the LPN/LVN give the client? Please enter the numeric value for the total score on the blank.  The LPN/LVN enters the client’s room and notes the client looking spontaneously around the room. The client is able to state their name, date of birth, and allergies when prompted for that information. The client tells the LPN/LVN where they are and why they are here. The LPN/LVN asks for permission to assess the client’s vitals and the client lifts the right arm for the nurse to apply the blood pressure cuff. The client’s blood pressure is 114/72, heart rate is 81, respiratory rate is 16, and temperature is 37.9 C (100.2F). The client rates their pain a 2/10 and describes it as a dull ache behind the left eye. The client’s grip on the right is slightly weaker than that on the left. The lower extremity strength is equally weak. Capillary refill is less than 3 seconds on the upper and lower extremities. The pulses are strong in the upper and lower extremities. 

The nurse is caring for a hospitalized client in the onset stage of Guillain-Barre syndrome. Which complication is most important for the nurse to monitor for?

A 16-year-old and his friends are swimming in a river in their neighborhood.  He climbs a tree and dives headfirst into the river.  After a few seconds, his friends realize something is wrong.  They pull him onto the riverbank.  He is conscious and breathing, but unable to move. What should they do first?

On assessment the LPN/LVN found the client’s pupils as pictured below. What term should the LPN/LVN use to document this?