The nurse admits a 2 year-old child who has had a seizure. W...

The nurse admits a 2 year-old child who has had a seizure. Which of the following statement by the child's parent would be important in determining the etiology of the seizure?

A. He has been taking long naps for a week.'
B. He has had an ear infection for the past 2 days.'
C. He has been eating more red meat lately.'
D. He seems to be going to the bathroom more frequently.'

Correct Answer: B

Rationale: He has had an ear infection for the past 2 days.' Contributing factors to seizures in children include those such as age (more common in first 2 years), infections (late infancy and early childhood), fatigue, not eating properly and excessive fluid intake or fluid retention.

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A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?

A. Oral Coumadin therapy
B. Heparin 5000 units subcutaneously B.I.D.
C. Heparin infusion to maintain the PTT at 1.5-2.5 times the control value
D. Heparin by subcutaneous injection to maintain the PTT at 1.5 times the control value

Correct Answer: C

Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.

The nurse is collecting data from a client with primary adrenal insufficiency (Addison disease). Which of the following findings is consistent with the condition?

A. Bronze pigmentation of the skin
B. Increased body and facial hair
C. Purple or red striae on the abdomen
D. Supraclavicular fat pad

Correct Answer: A

Rationale: Bronze skin pigmentation (A) is a hallmark of Addison disease due to increased ACTH stimulating melanocytes. Increased hair (B) and supraclavicular fat pad (D) are associated with Cushing syndrome, while striae (C) are nonspecific but not typical of Addison disease.

The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.

A. Client develops right-sided upper and lower extremity drift
B. Client found lying unconscious on the floor
C. Client has order for heparin with surgery planned for the morning
D. Client has serum sodium of 124 mEq/L (124 mmol/L)
E. Client refuses a prescribed, routine pain medication

Correct Answer: A,B,C,D

Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.

When using an interpreter to teach a client about a procedure to do in the home, the nurse should take which approach?

A. Speak directly to the interpreter while presenting information and use pauses for questions
B. Talk to the interpreter in advance and leave the client and interpreter alone
C. Include a family member and direct communications to that person
D. Face the client while presenting the information as the interpreter talks in the native language

Correct Answer: D

Rationale: Face the client while presenting the information as the interpreter talks in the native language. This allows non-verbal communication and maintains a client-focused approach.

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

A. Ensuring bed alarm remains activated
B. Initiating an hourly rounding schedule
C. Inserting an indwelling urinary catheter
D. Moving client to a room close to the nurses' station
E. Raising all side rails of the client's bed

Correct Answer: A,B,D

Rationale: Bed alarms (A), hourly rounding (B), and proximity to the nurses' station (D) enhance safety and monitoring. Catheters (C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.