Nokea
The client is in status epilepticus. Which interventions, if prescribed, should be included in this client's immediate treatment? Select all that apply.
- A. Administer dexamethasone intravenously.
- B. Give oxygen and prepare for endotracheal intubation.
- C. Obtain a defibrillator and prepare to use it immediately.
- D. Remove nearby objects to protect the client from injury.
- E. Administer lorazepam intravenously STAT.
Correct Answer: B,D,E
Rationale: Anticonvulsant medications such as phenytoin (Dilantin), and not anti-inflammatory medications such as dexamethasone (Decadron), are administered IV to control seizure activity. Status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway. Defibrillation is treatment for ventricular fibrillation, a lethal heart dysrhythmia. Care is taken to protect the client from injury during the seizure. Either lorazepam (Ativan) or diazepam (Valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin.
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When the nurse alternates injection sites on the client's upper arms, how far apart should the injections be spaced?
- A. 1/4'' (0.6 cm)
- B. 1/2'' (1.3 cm)
- C. 1'' (2.5 cm)
- D. 2'' (5 cm)
Correct Answer: C
Rationale: Injections should be spaced 1'' apart to prevent tissue irritation and ensure proper drug absorption.
Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'
- A. Explain to the client, 'Your mother died several years ago.'
- B. Tell the client, 'Your mother will visit later.'
- C. State, 'You miss your mother. What was she like?'
- D. Ask the client, 'When did you last see your mother?'
Correct Answer: C
Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.
The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
Because the client with Parkinson's disease is prone to constipation, the nurse should encourage increased consumption of which food?
- A. Fresh fruits
- B. Wheat pasta
- C. Low-fat cheese
- D. Canned vegetables
Correct Answer: A
Rationale: Fresh fruits are high in fiber, which helps alleviate constipation in clients with Parkinson's disease.
Before the client undergoes the craniotomy, the nurse inserts a urinary catheter. How far should the catheter be inserted if the client is a male?
- A. 2'' to 4'' (5 to 10 cm)
- B. 4'' to 6'' (10 to 15 cm)
- C. 6'' to 8'' (15 to 20 cm)
- D. 8'' to 10'' (20 to 25.5 cm)
Correct Answer: D
Rationale: For a male, the urinary catheter should be inserted 8'' to 10'' to reach the bladder adequately.