Nokea
During seizure activity which observation is the priority to enhance further direction of treatment?
- A. Observe the sequence or types of movement
- B. Note the time from beginning to end
- C. Identify the pattern of breathing
- D. Determine if loss of bowel or bladder control occurs
Correct Answer: A
Rationale: Observe the sequence or types of movement. Noting movement types is critical for diagnosis and guiding treatment.
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A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?
- A. Double vision and visual halos
- B. Extremity tingling and numbness
- C. Confusion and lightheadedness
- D. Sensitivity of sunlight
Correct Answer: B
Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.
A child in Bryant's traction. The nurse notes that the foot of the uninjured leg feels warmer to touch than that of the broken leg during neurovascular assessment.
The nurse should
- A. record the observation.
- B. encourage the child to move the foot.
- C. cover the colder foot with a sock.
- D. notify the physician.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) ignores possibility that Ace bandage is too tight (2) does not relieve the circulation problem (3) does not relieve the circulation problem (4) correct-assessment indicates that Ace bandage is too tight and needs readjusting
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
A primigravida client, 10-days postpartum, who is anxious about caring for her newborn. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
The homecare nurse is scheduling clients for the day. Which of the following clients should the nurse visit FIRST?
- A. A primigravida client, 10-days postpartum, who is anxious about caring for her newborn.
- B. A middle-aged client, 6-days postoperative, who is complaining of pain in his midsternal incision.
- C. A client with AIDS who had a chest tube removed yesterday and is complaining of crackling under his skin.
- D. A client who receives amiloride hydrochloride (Midamor) and states that she is dizzy when she gets up in the morning.
Correct Answer: C
Rationale: Strategy: Identify the least stable client by eliminating the more stable clients. (1) psychosocial need, physical issues take priority (2) complaints require follow-up, but not the most unstable client (3) correct-describes subcutaneous emphysema, which is indication of pneumothorax; observe client for respiratory distress, contact physician (4) postural hypotension a side effect of diuretic therapy, change position slowly
During a prenatal visit, a client states: 'I have been very nauseated during my first trimester, and I don't understand the reason.' Which of the following responses by the nurse is BEST?
- A. You are nauseated because of the fatigue you are feeling.'
- B. The nausea is due an increase in the basal metabolic rate.'
- C. The nausea is caused by a secondary elevation in the hormones produced by the endocrine system.'
- D. If you eat different kinds of foods, you won't be nauseated.'
Correct Answer: C
Rationale: during first trimester, nausea and vomiting are related to elevation in estrogen, progesterone, and hCG from the endocrine system