Nokea
A 16-year-old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission, he begins to have a grand mal seizure. Which action should the nurse take?
- A. Obtain assistance in holding him to prevent injury.
- B. Observe him carefully.
- C. Call a CODE.
- D. Place a padded tongue blade between the teeth.
Correct Answer: B
Rationale: During a grand mal seizure, the priority action for the nurse is to ensure the safety of the client. Observing the client carefully allows the nurse to monitor the seizure activity, the client's breathing, and any signs of distress without interfering with the seizure process. Restraining the client or placing objects in the mouth can lead to injury and should be avoided. Calling a CODE is not appropriate for a seizure as it is a normal response to the client's condition.
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A child is recovering from an appendectomy. The parent asks when the child can resume normal activities. What is the best response by the nurse?
- A. The child can resume normal activities as soon as they feel up to it
- B. The child should avoid strenuous activities for at least 2 weeks
- C. The child can resume normal activities after the stitches are removed
- D. The child should avoid all physical activities for the next month
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 10-year-old child is being discharged after being admitted for status asthmaticus. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Use a peak flow meter daily to monitor asthma control
- B. Avoid exposure to known allergens
- C. Continue taking asthma medications as prescribed
- D. Seek emergency care if symptoms worsen
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a 10-year-old child who is scheduled for surgery to repair a fractured femur. The child's parent expresses concern about the child being afraid of the surgery. What is the nurse's best response?
- A. Children at this age are usually not afraid of surgery
- B. It's normal for your child to feel scared. Let's talk about what to expect
- C. You should talk to the surgeon about your child's fear
- D. Don't worry, your child will be fine
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A parent of a 2-month-old infant, who was treated for pyloric stenosis, is receiving discharge instructions from a healthcare provider. Which statement by the parent indicates a need for further teaching?
- A. We will burp our baby more frequently during feedings
- B. We should feed our baby in an upright position
- C. We will lay our baby on their stomach after feeding
- D. We will start feeding our baby with small, frequent feedings
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.