Nokea
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
- A. I will gently restrain him during seizures.
- B. I will loosen his clothing during seizures.
- C. I will insert a washcloth in his mouth during seizures.
- D. I will turn him on his back during seizures.
Correct Answer: B
Rationale: Loosening clothing ensures airway safety and comfort during a seizure.
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Nurses'Notes
Day 1:
Client reports to clinic following trip to emergency department (ED) after a fall at home. Reports slipping
on a floor rug and hurting left ankle.
ray report taken in ED shows left lateral malleolus fracture. Removable boot immobilizer in place, using
a cane for assistance in ambulating
Boot immobilizer removed, left ankle with edema +2. Client reports pain as 6 on a scale of 0 to 10.
Client states they were prescribed pain medication by ED provider. Client lives alone.
Reports being "down to 1⁄2 pack of cigarettes, least 3 cups of coffee daily. States their mother was
always breaking something.
Day 3:
Bone Mineral Density DEXA scan -3.8 (-1 or above)
Based on the client's laboratory and diagnostic results, indicate which of the following provider
prescriptions the nurse should expect.
A nurse in a provider's clinic is assisting in the care of an older adult female client.
For each provider prescription click to specify if the provider prescription is expected or unexpected for
the client. There must be at least 1 selection in every row. There does not need to be a selection in every
column.
- A. Physical therapy for muscle-strengthening and balance-training
- B. Calcium 1500 mg po once daily on empty stomach
- C. Vitamin D supplement 2,500 units daily
- D. Home health evaluation of home safety
- E. Increase caffeine intake
- F. Increase daily sun exposure
Correct Answer: A, B, C, D
Rationale: A: Improves strength and reduces fall risk. B, C: Address osteoporosis (DEXA -3.8). D: Ensures safe environment.
A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?
- A. Determine if the client has a support system.
- B. Schedule a mental health consult for the client.
- C. Provide the client with information about coping strategies.
- D. Encourage the client to attend a support group.
Correct Answer: A
Rationale: Assessing the support system first identifies resources to address ineffective coping.
A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?
- A. Use a narrower cuff to repeat the BP measurement.
- B. Request a prescription for an antihypertensive medication.
- C. Deflate the cuff faster when repeating the BP measurement.
- D. Measure the client's BP in the other arm.
Correct Answer: D
Rationale: Measuring in the other arm verifies the sudden BP increase, ruling out measurement error.
A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Squeeze the client's finger until a blood drop forms
- B. Prick the side of the client's finger.
- C. Elevate the client's hand above the level of the heart
- D. Cleanse the client's finger with an iodine swab
- E. Using clean gloves
Correct Answer: B, E
Rationale: B: Pricking the side avoids painful areas. E: Clean gloves ensure infection control.
A nurse is reinforcing discharge teaching with a male client who has an indwelling urinary catheter. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will clamp the tube when I go for a walk.
- B. I will keep the drainage bag below the level of my waist.
- C. I will empty my drainage bag once a day.
- D. I will apply antiseptic ointment to the tip of my penis.
Correct Answer: B
Rationale: Keeping the bag below the waist prevents urine backflow and infection.