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The client who just had a three (3)-minute seizure has no apparent injuries and is oriented to name, place, and time but is very lethargic and just wants to sleep. Which intervention should the nurse implement?
- A. Perform a complete neurological assessment.
- B. Awaken the client every 30 minutes.
- C. Turn the client to the side and allow the client to sleep.
- D. Interview the client to find out what caused the seizure.
Correct Answer: C
Rationale: Post-seizure, the client is in a postictal phase with lethargy. Turning to the side (C) prevents aspiration and allows safe rest. Neurological assessment (A) can wait until the client is less lethargic, frequent awakening (B) is unnecessary if oriented, and interviewing (D) is not urgent.
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The client is diagnosed with meningococcal meningitis. Which preventive measure would the nurse expect the health-care provider to order for the significant others in the home?
- A. The Haemophilus influenzae vaccine.
- B. Antimicrobial chemoprophylaxis.
- C. A 10-day dose pack of corticosteroids.
- D. A gamma globulin injection.
Correct Answer: B
Rationale: Close contacts of meningococcal meningitis patients require antimicrobial chemoprophylaxis (B), such as rifampin, to prevent infection. Vaccines (A) are not for immediate prophylaxis, corticosteroids (C) treat inflammation, and gamma globulin (D) is not indicated.
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.
Which sign or symptom in the client's medical history would most likely indicate a manifestation of the client's disease?
- A. Sudden hearing loss
- B. Sensitivity to light
- C. Drooping eyelids
- D. Protruding tongue
Correct Answer: C
Rationale: Drooping eyelids (ptosis) is a common symptom of myasthenia gravis due to muscle weakness affecting the ocular muscles.
Which clinical manifestation is the educator most likely to include as the initial sign of Parkinson's disease?
- A. Muscle rigidity
- B. Muscle tremors
- C. Muscle weakness
- D. Muscle deterioration
Correct Answer: B
Rationale: Muscle tremors, particularly resting tremors, are often the initial sign of Parkinson's disease.
Which intervention is most appropriate for a client diagnosed with Bell's palsy?
- A. Reduce the amount of light in the room.
- B. Advise the client to drink liquids from a straw.
- C. Inspect the buccal pouch for food after eating.
- D. Instruct the client on how to walk with a cane.
Correct Answer: B
Rationale: Drinking from a straw helps clients with Bell's palsy manage liquids, compensating for facial muscle weakness.