Nokea
Before, during and after seizure. The nurse knows that the patient is ALWAYS placed in what position?
- A. Low fowler’s
- B. Modified trendelenburg
- C. Side lying
- D. Supine NERVOUS SYSTEM
Correct Answer: C
Rationale: The correct answer is C: Side lying position. This position helps prevent aspiration of secretions and promotes drainage from the mouth during and after a seizure. Placing the patient in a side lying position also helps prevent injury from falling and facilitates monitoring of the patient's airway.
Incorrect choices:
A: Low fowler's - This position does not provide optimal airway protection and may increase the risk of aspiration during a seizure.
B: Modified trendelenburg - This position may worsen the patient's airway patency and does not facilitate drainage of secretions.
D: Supine - Placing the patient in a supine position can lead to aspiration and compromise the airway, especially during a seizure.
Summary: The side lying position is the most appropriate choice as it ensures airway protection, facilitates drainage, and reduces the risk of aspiration during and after a seizure.
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The nurse has entered a client’s room to find the client diaphoretic (sweat-covered) and shivering, inferring that the client has a fever. How should the nurse best follow up this cue and inference?
- A. Measure the client’s oral temperature.
- B. Ask a colleague for assistance.
- C. Give the client a clean gown and warm blankets.
- D. Obtain an order for blood cultures.
Correct Answer: A
Rationale: Step 1: Assess the client's vital signs to confirm presence of fever.
Step 2: Measure client's oral temperature to obtain accurate reading.
Step 3: Document temperature and report findings to healthcare provider.
Step 4: Initiate appropriate interventions based on temperature reading.
Step 5: Reassess client's condition to evaluate effectiveness of interventions.
Summary: Option A is correct as it directly addresses the cue of fever by confirming the temperature. Options B, C, and D are incorrect as they do not directly address the need to assess the client's temperature for accurate evaluation and intervention.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should primarily communicate with the patient, not just the daughter. The nurse should engage the patient in conversation, address them directly, and ensure their needs and concerns are being addressed. Speaking only to the daughter could neglect the patient's autonomy and lead to potential communication barriers. Choices A, C, and D are incorrect as they all involve appropriate communication techniques with the patient, such as making eye contact, leaning forward to show attentiveness, and nodding to indicate understanding. These actions demonstrate good communication skills and rapport-building with the patient, which are important in nursing practice.
A new nurse is completing an assessment on an 80-year-old patient who is alert and oriented. The patient’s daughter is present in the room. Which action by the nurse will require follow-up by the charge nurse?
- A. The nurse makes eye contact with the patient.
- B. The nurse speaks only to the patient’s daughter.
- C. The nurse leans forward while talking with the patient.
- D. The nurse nods periodically while the patient is speaking.
Correct Answer: B
Rationale: The correct answer is B because the nurse should always prioritize communication with the patient, especially when the patient is alert and oriented. Speaking only to the patient's daughter could undermine the patient's autonomy and right to be involved in their care. It is important for the nurse to directly address the patient to gather accurate information and ensure patient-centered care. Making eye contact (A), leaning forward (C), and nodding periodically (D) are all appropriate communication techniques that show attentiveness and engagement with the patient, which are crucial in building rapport and trust.
A patient who is recovering from a stroke becomes easily frustrated when unable to complete a task. Which of the ff. responses by the nurse will best help the patient get the task done?
- A. Perform the task for the patient
- B. Tell the patient not to worry about it
- C. Break the task down into simple steps
- D. Have another patient demonstrate how to perform the task
Correct Answer: C
Rationale: The correct answer is C: Break the task down into simple steps. This response is the best because it helps the patient by breaking down the task into manageable parts, making it less overwhelming and more achievable. By providing clear and simple steps, the patient can focus on one aspect at a time, reducing frustration and increasing the likelihood of successful completion.
Choice A is incorrect because performing the task for the patient does not promote independence or skill development. Choice B is incorrect as it dismisses the patient's feelings of frustration without offering a solution. Choice D is incorrect because having another patient demonstrate may not address the specific needs and abilities of the recovering stroke patient.
The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
- A. Difficulty hearing
- B. Confusion
- C. Bronchospasm
- D. Agranulocytosis
Correct Answer: C
Rationale: The correct answer is C: Bronchospasm. Antiplatelet drugs commonly cause hypersensitivity reactions like bronchospasm due to their effects on platelet function. They can trigger an allergic response leading to bronchoconstriction. Difficulty hearing (A) is not a common hypersensitivity reaction to antiplatelet therapy. Confusion (B) is more commonly associated with central nervous system effects rather than hypersensitivity reactions. Agranulocytosis (D) is a severe drop in white blood cells and is not typically a hypersensitivity reaction to antiplatelet drugs.