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A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
- A. It is common in children who take barbiturates.
- B. It usually occurs after seizures; let him sleep.
- C. It is probably not related to his seizure disorder or treatment.
- D. It is probably a warning sign that he is about to have a seizure.
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.
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The nurse is caring for a client with a history of schizophrenia.
- A. Which client behavior indicates a positive response to antipsychotic medication?
- B. Increased social withdrawal.
- C. Improved ability to focus on tasks.
- D. Frequent auditory hallucinations.
- E. Increased agitation and pacing.
Correct Answer: B
Rationale: Improved ability to focus on tasks indicates reduced psychotic symptoms and better cognitive function, a positive response to antipsychotics. Withdrawal, hallucinations, and agitation suggest poor response.
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
Assessment findings the nurse could expect to find in the infant with biliary atresia are:
- A. Excessive drooling that requires frequent suctioning
- B. Pale, frothy stools, and poor weight gain
- C. Poor tissue turgor and weight loss
- D. Clay-colored stools and abdominal distention
Correct Answer: D
Rationale: Biliary atresia causes bile duct obstruction, leading to clay-colored stools and abdominal distention from liver enlargement, so D is correct. Answers A, B, and C are not specific to biliary atresia.
An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
- A. a coping strategy.
- B. a defense mechanism.
- C. a way to not bother the nurse.
- D. regression.
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.
The nurse is performing a physical assessment on a client with insulin dependent diabetes mellitus. Which client finding calls for immediate nursing action?
- A. Diaphoresis and shakiness
- B. Reduced lower leg sensation
- C. Intense thirst and hunger
- D. Painful hematoma on thigh
Correct Answer: A
Rationale: Diaphoresis and shakiness. Diaphoresis is a sign of hypoglycemia, which warrants immediate attention to prevent severe complications.