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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A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. The intended outcome of administering oral neomycin before surgery is to:
- A. Prevent postoperative bladder infection.
- B. Reduce the number of intestinal bacteria.
- C. Decrease the potential for postoperative hypostatic pneumonia.
- D. Increase the body's immunologic response to the stressors of surgery.
Correct Answer: B
Rationale: Oral neomycin is administered preoperatively to reduce intestinal bacteria, decreasing the risk of infection during bowel surgery. It does not target bladder infections, pneumonia, or immune response directly. CN: Pharmacological and parenteral therapies; CL: Apply
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
Which intervention supports a client with expressive aphasia?
- A. Speak loudly.
- B. Use written instructions.
- C. Provide a communication board.
- D. Ask complex questions.
Correct Answer: C
Rationale: A communication board supports communication for clients with expressive aphasia.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.
An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:
- A. Left ventricular atrophy.
- B. Irregular heartbeats.
- C. Peripheral vascular occlusion.
- D. Pacemaker placement.
Correct Answer: A
Rationale: Aging leads to left ventricular atrophy, reducing cardiac reserve and impairing the heart's ability to respond to stress, unlike irregular heartbeats or pacemakers.