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A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.
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A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?
- A. The assistive personnel's ability to complete the task without assistance
- B. The assistive personnel's level of experience and competency in performing the task
- C. The assistive personnel's rapport with clients
- D. The assistive personnel's availability at the time of the delegation
Correct Answer: B
Rationale: The correct answer is B: The assistive personnel's level of experience and competency in performing the task. When delegating tasks, the nurse must consider the individual's ability to safely and effectively perform the task. Choosing someone with the appropriate experience and competency minimizes the risk of errors or harm to the patient. Additionally, considering the person's level of experience ensures that they have the necessary skills to handle the task independently. Choices A, C, and D are incorrect as they do not directly address the crucial aspect of competency and experience required for safe delegation.
A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client's nutritional status?
- A. Restrict drinking fluids before and during meals
- B. Plan medication doses to occur before meals
- C. Increase the amount of fat and carbohydrates in meals
- D. Eat three large meals per day
Correct Answer: B
Rationale: The correct answer is B: Plan medication doses to occur before meals. This is because Myasthenia gravis can cause difficulty swallowing, leading to weight loss. Taking medication before meals can enhance the client's ability to eat by improving muscle strength for swallowing and chewing. Restricting fluids (A) may exacerbate swallowing difficulties. Increasing fat and carbohydrates (C) can lead to weight gain but may not address the swallowing issue. Eating three large meals (D) may be challenging for someone with swallowing difficulties.
A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects?
- A. Seasonal allergies
- B. Mitral valve disease
- C. Nasal polyps
- D. Asthma
Correct Answer: D
Rationale: The correct answer is D: Asthma. Clients with asthma are especially vulnerable to the effects of ozone due to their compromised respiratory system. Ozone can trigger asthma symptoms and exacerbate respiratory distress in individuals with asthma. Asthma is a chronic inflammatory condition of the airways, making it more susceptible to damage from environmental pollutants like ozone. Seasonal allergies (A), mitral valve disease (B), and nasal polyps (C) are not directly related to respiratory function and therefore not as vulnerable to ozone effects. In summary, asthma is the correct answer because of its direct impact on the respiratory system, making individuals with asthma more susceptible to the harmful effects of ozone.
A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY
- A. Assign the client to a private room
- B. Remove client and transport crew from the Emergency department
- C. Contact decontamination team
- D. Call the scene to identify the chemical
- E. Immediately remove the saturated clothing from the client
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
1. Option B - Removing the client and transport crew from the Emergency department is crucial to prevent potential contamination of others and ensure safety.
2. Option C - Contacting the decontamination team is essential to properly manage and decontaminate the client and the area.
3. Option E - Removing the saturated clothing from the client immediately helps eliminate further exposure and contamination risks.
Incorrect Answers:
A: Assign the client to a private room - This is not the priority as immediate decontamination and safety measures are needed.
D: Call the scene to identify the chemical - Identifying the substance is important but not the priority when the client's safety is at risk.
The nurse is working on discharge planning for a 25-year-old hospitalized client diagnosed with Multiple Sclerosis (MS). The client has significant bilateral lower extremities muscle weakness. Which of the following facilities should the nurse expect this client to be discharged to?
- A. Home care services
- B. Sub-acute care facility
- C. Rehabilitation facility
- D. Skilled nursing facility
Correct Answer: C
Rationale: The correct answer is C: Rehabilitation facility. This is the appropriate choice because a rehabilitation facility specializes in providing intensive therapy and support for clients with muscle weakness, such as the client with MS in this case. The client needs structured rehabilitation services to improve muscle strength and function. Home care services (A) may not provide sufficient support and resources for the client's needs. Sub-acute care facility (B) is more suitable for clients who require ongoing medical care or monitoring. Skilled nursing facility (D) is typically for clients who need long-term nursing care rather than intensive rehabilitation.