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A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching?
- A. My child may experience incontinence.'
- B. My child may seem confused afterwards.'
- C. My child may stare and seem inattentive.'
- D. My child will notice unusual odors prior to the event.'
Correct Answer: C
Rationale: Staring and inattention (C) are hallmark signs of absence seizures. Incontinence (A) and confusion (B) are more typical of other seizures, and odors (D) suggest an aura, not typical in absence seizures.
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A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. No one is in your room. Let's get you more medicine.'
- B. I do not see anyone, but you seem to be very frightened.'
- C. No one can hurt you here.'
- D. Just tell the person to go away.'
Correct Answer: B
Rationale: It is important to acknowledge the client's fear. The other responses deny the client's perceptions.
A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.
The nurse is reinforcing medication instructions for the parents of a child prescribed amoxicillin/clavulanate (liquid) twice a day for acute sinusitis. Which instructions are most important for the parents to remember? Select all that apply.
- A. Administer the medication with food if nausea or diarrhea develops
- B. Complete the medication course even if the child is better
- C. Rash is a normal, expected side effect
- D. Shake the medicine well before use
- E. Use a household spoon to measure the dose
Correct Answer: A, B, D
Rationale: Taking with food (A) reduces GI upset, completing the course (B) prevents resistance, and shaking well (D) ensures proper dosing. Rash (C) is not normal and requires evaluation, and household spoons (E) are inaccurate.
The nurse helps the health care provider perform a thoracentesis at the bedside. In which position does the nurse place the client to facilitate needle insertion and promote comfort?
- A. Fetal position, lying on unaffected side with knees drawn to the abdomen and hands clasped around them
- B. Lying on the affected side with head of the bed elevated to 30-45 degrees
- C. Prone with head turned to the affected side and arms over the head, supported by a pillow
- D. Upright leaning forward over the bedside table, with arms supported on pillows
Correct Answer: D
Rationale: Upright leaning forward (D) facilitates lung expansion and fluid access while ensuring comfort. Other positions (A, B, C) are less effective or uncomfortable.
The nurse reviews the ECG of a client. Which prescribed medication should the nurse suspect as the cause of the ECG findings?
- A. Captopril
- B. Carvedilol
- C. Glipizide
- D. Levothyroxine
Correct Answer: D
Rationale: Levothyroxine (D) can cause arrhythmias, which may be reflected in ECG changes. Captopril (A), Carvedilol (B), and Glipizide (C) are less likely to cause significant ECG alterations.