Nokea
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
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Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?
- A. Assessing the client's skin color.
- B. Abrupting the respiratory rate.
- C. Verifying the amount of cuff inflation.
- D. Auscultating breath sounds bilaterally.
Correct Answer: D
Rationale: Auscultating bilateral breath sounds confirms correct endotracheal tube placement in both lungs. Skin color, respiratory rate, and cuff inflation are less specific.
The nurse administers fat emulsion solution during TPN as ordered based on the understanding that this type of solution:
- A. Provide essential fatty acids.
- B. Provides extra carbohydrates.
- C. Promotes effective metabolism of glucose.
- D. Maintains a normal body weight.
Correct Answer: A
Rationale: Fat emulsion solutions in TPN provide essential fatty acids to prevent deficiency. They do not primarily provide carbohydrates, promote glucose metabolism, or maintain body weight. CN: Pharmacological and parenteral therapies; CL: Apply
The nurse is caring for a child who is immunocompromised and diagnosed with varicella. The nurse should request a prescription from the physician for which medication?
- A. amoxicillin-clavulanate
- B. acyclovir
- C. doxycycline
- D. azithromycin
Correct Answer: B
Rationale: Acyclovir is an antiviral medication used to treat varicella (chickenpox) in immunocompromised patients to reduce severity and complications. Choice A (amoxicillin-clavulanate) and Choice D (azithromycin) are antibiotics, ineffective against viral infections. Choice C (doxycycline) is an antibiotic and not suitable for children under 8 due to the risk of tooth discoloration.
Which of the following is an environmental factor and increases the risk of cancer?
- A. Gender.
- B. Nutrition.
- C. Immunologic status.
- D. Age.
Correct Answer: B
Rationale: Nutrition is an environmental factor that influences cancer risk, as diets high in processed foods or low in fiber can increase the risk of cancers like colon cancer.
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.