Nokea
A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?
- A. I should make sure he gets plenty of rest.'
- B. I should get him a medic alert bracelet.'
- C. I should lay him on his back during a seizure.'
- D. I should loosen his clothing during a seizure.'
Correct Answer: C
Rationale: Laying a seizing child on their back risks aspiration; the correct position is on the side. The other statements reflect appropriate seizure management. Reduction of Risk Potential
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The nurse is assessing a client with a history of migraines. Which of the following symptoms would the nurse expect the client to report?
- A. Bilateral dull headache.
- B. Photophobia and nausea.
- C. Constant daily headache.
- D. Pain relieved by physical activity.
Correct Answer: B
Rationale: Migraines typically cause unilateral throbbing pain with photophobia and nausea due to neurological sensitivity. Bilateral dull pain (A) suggests tension headache, constant pain (C) indicates chronic headache, and activity (D) worsens migraines.
A client, age 21, is admitted with bacterial meningitis. Which hospital room would be the appropriate choice for this client?
- A. A private room down the hall from the nurses' station
- B. An isolation room close to the nurses' station
- C. A semiprivate room with a 32-year-old client who has viral meningitis
- D. A two-bed room with a client who previously had bacterial meningitis
Correct Answer: B
Rationale: A client with bacterial meningitis should be kept in isolation for at least 24 hours after admission and, during the initial acute phase, should be as close to the nurses' station as possible to allow maximal observation. Placing the client in a room with a client who has viral meningitis may cause harm to both clients because the organisms causing viral and bacterial meningitis differ; either client may contract the other's disease. Immunity to bacterial meningitis can't be acquired; therefore, a client who previously had bacterial meningitis shouldn't be put at risk by rooming with a client who has just been diagnosed with this disease.
In a client who's predisposed to bipolar disorder, a bipolar episode might be triggered by:
- A. hypothyroidism
- B. hyperglycemia
- C. hypertension
- D. antiseizure medication
Correct Answer: A
Rationale: Hypothyroidism might trigger a bipolar episode in a client predisposed to bipolar disorder. Episodes aren't known to be triggered by hyperglycemia, hypertension, or antiseizure medications.
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
- A. Reduce fear and protect self-esteem
- B. Minimize anxiety and delay apprehension
- C. Avoid conflict and leave unpleasant situations
- D. Increase independence and communicate more often
Correct Answer: A
Rationale: Reduce fear and protect self-esteem. Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.
The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.