Nokea
A nurse plans care for a client with epilepsy. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)
- A. Keep bed rails up at all times.
- B. Maintain the client on strict bedrest.
- C. Ensure that the client has IV access.
- D. Provide a high-protein diet.
- E. Keep oxygen and suction equipment available.
Correct Answer: A,C,E
Rationale: Oxygen and suctioning equipment with an airway must be readily available. Bed rails should be up at all times to prevent injury from a fall during a seizure. A saline lock provides venous access for IV drug therapy to manage seizures. Padded tongue blades are dangerous, dietary restrictions are not indicated, and strict bedrest is not necessary.
You may also like to solve these questions
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.)
- A. Sodium levels
- B. Clotting factors
- C. White blood cell count
- D. C-reactive protein
- E. Liver enzymes
Correct Answer: A,B
Rationale: Inflammation from meningitis can stimulate the hypothalamus, leading to excessive antidiuretic hormone production, causing syndrome of inappropriate antidiuretic hormone (SIADH); thus, sodium levels should be monitored. Systemic inflammatory response syndrome (SIRS) can lead to coagulopathy and disseminated intravascular coagulation, requiring monitoring of clotting factors. Other values are not specific to meningitis complications.
A nurse cares for a client with advanced Alchimers disease. The clients caregiver states, She is always wandering off. What can I do to manage this restless behavior? How should the nurse respond?
- A. This is a sign of fatigue. The client would benefit from a daily nap.
- B. Engage the client in scheduled activities throughout the day.
- C. It sounds like this is difficult for you. I will consult the social worker.
- D. The provider can prescribe a mild sedative for restlessness.
Correct Answer: B
Rationale: Several strategies may be used to cope with restlessness and wandering in Alzheimer's disease. Engaging the client in structured activities throughout the day is effective. Daily naps and sedatives are less effective, and consulting a social worker does not directly address the behavior.
A nurse delegates care for a client with Parkinson disease to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this clients care?
- A. Assist the client with frequent and meticulous oral care.
- B. Assess the clients ability to eat and swallow before each meal.
- C. Schedule appointments early in the morning to ensure rest in the afternoon.
- D. Monitor the client's blood pressure every hour.
Correct Answer: A
Rationale: Frequent and meticulous oral care is important for clients with Parkinson disease due to swallowing difficulties and drooling, which increase the risk of oral complications. Assessing swallowing is a nursing responsibility, not suitable for UAP delegation. Scheduling appointments and frequent blood pressure monitoring are not specific to Parkinson disease care.
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.)
- A. Photophobia
- B. Dilated pupils
- C. Headache
- D. Widened pulse pressure
- E. Bradycardia
Correct Answer: B,D,E
Rationale: Increased ICP in encephalitis is indicated by dilated pupils, widened pulse pressure, bradycardia, irregular respirations, and less responsive pupils. Photophobia and headache are symptoms of encephalitis but not specific to increased ICP.
A nurse is teaching a client who experiences migraine headaches. Which statement should the nurse include in the teaching to help prevent the onset of migraine headaches?
- A. Wear dark sunglasses when you are in brightly lit spaces.
- B. Lie down in a darkened room when you experience a headache.
- C. Set your alarm to ensure you do not sleep longer than 6 hours at one time.
- D. Take over-the-counter pain relievers as soon as the headache starts.
Correct Answer: B
Rationale: At the onset of a migraine attack, lying down in a darkened room can alleviate pain. The client may cover both eyes and use a cool cloth on the forehead. If the client falls asleep, they should remain undisturbed. The other options are not recognized therapies for migraines.