Nokea
A client’s partner asks the nurse if ‘staring off into space’ is a seizure because the client ‘does that sometimes when having a seizure.’ Which response from the nurse is the most helpful?
- A. No, absence seizures can look like daydreaming or staring off into space.
- B. No, you are wrong. Don’t worry about that.
- C. Yes, so please let me know if you see the client do that.
- D. You don’t have to monitor the client for seizures.
Correct Answer: A
Rationale: Explaining that absence seizures can appear as staring or daydreaming educates the partner accurately and encourages reporting without alarm. Dismissing the concern, assuming it’s a seizure, or discouraging monitoring is unhelpful and potentially unsafe.
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Medication bound to protein can have which of the following effects?
- A. enhancement of drug availability
- B. rapid distribution of the drug to receptor sites
- C. less availability to produce desired medicinal effects
- D. increased metabolism of the drug by the liver
Correct Answer: C
Rationale: Protein-bound drugs are less available for receptor binding, reducing their therapeutic effect until unbound. This does not enhance availability, speed distribution, or increase metabolism directly. Pharmacological Therapies
The nurse is talking with a client who has schizophrenia. The client states, 'I had a pet rabbit when I was growing up. Carrots are probably my favorite vegetable. Do you know that oranges grow on trees?' The nurse should recognize that the client is demonstrating
- A. associative looseness
- B. concrete thinking
- C. tangentiality
- D. neologisms
Correct Answer: C
Rationale: Tangentiality involves shifting topics without clear connections, as seen in the client’s unrelated statements about rabbits, carrots, and oranges. Associative looseness is more disorganized, concrete thinking lacks abstract thought, and neologisms involve invented words.
The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching?
- A. I will allow my child to have a snack while using the HFCWO vest to encourage cooperation.
- B. I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest.
- C. I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable.
- D. My child will use the HFCWO vest once in the morning, once in the evening, and as needed.
Correct Answer: A
Rationale: Eating during HFCWO vest use can increase the risk of aspiration or reduce therapy effectiveness, indicating a need for further teaching. Bronchodilators during therapy, manual percussion as a backup, and the described frequency are appropriate.
How often must physical restraints be released?
- A. every 2 hours
- B. between 1 and 3 hours
- C. every 30 minutes
- D. at least every 4 hours
Correct Answer: A
Rationale: Physical restraints must be released every 2 hours to assess skin, circulation, and comfort, with checks every 30 minutes while restrained. Safety and Infection Control
The nurse is caring for a client with bacterial meningitis who has been placed on droplet precautions. Which personal protection is mandatory for the nurse when administering medications?
- A. Face shield
- B. Gown
- C. N95 respirator
- D. Surgical mask
Correct Answer: D
Rationale: Droplet precautions for bacterial meningitis require a surgical mask to prevent transmission via respiratory droplets. A face shield, gown, or N95 respirator is not mandatory unless additional precautions are indicated.