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The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
- A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue.
- B. The nurse should help the mother restrain the child to prevent him from injuring himself.
- C. The nurse should call the operator to page for seizure assistance.
- D. The nurse should clear the area and position the client safely.
Correct Answer: D
Rationale: In this situation, the nurse's priority is to provide a safe environment for the patient during the seizure. Inserting a padded tongue blade (Option A) is not recommended as it can cause more harm than good, such as dental injury. Restraint of the patient (Option B) during a seizure is also not recommended as it can lead to injury. Calling the operator to page for seizure assistance (Option C) may delay immediate intervention. The best course of action is for the nurse to clear the area of any objects that may injure the patient during the seizure and position the client safely. This will help prevent injury and ensure the patient's safety until the seizure subsides.
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During the initial assessment, he is placed in a modified Trendelenburg position. What desired effect should the position have on the client?
- A. An increase in the client's blood pressure
- B. An increase in the client's respiratory rate f. An increase in the client's heart rate h. A decrease in blood loss
- C. An increase in the client's respiratory rate
- D. An increase in the client's heart rate h. A decrease in blood loss
Correct Answer: A
Rationale: Placing a client in a modified Trendelenburg position involves having the client lie flat on the back with the legs elevated above the level of the heart. The main purpose of this position is to help increase blood pressure in cases of hypotension or shock. By raising the legs above the heart level, gravity helps to facilitate the return of venous blood to the heart, which can increase cardiac output and, consequently, blood pressure. This position is commonly used in clinical settings to help improve perfusion to vital organs and assist in stabilizing a client's blood pressure.
You are explaining the risk of leukemia in children with Down syndrome to medical students; your discussion will include all the following statements EXCEPT
- A. acute leukemia occurs more frequently in children with Down syndrome than in the general population
- B. AML is more common in children with Down syndrome as compared to ALL
- C. children with Down syndrome have a slightly inferior outcome ratio of ALL/AML in general
- D. children with Down syndrome who develop AML demonstrate remarkable sensitivity to antimetabolites
Correct Answer: C
Rationale: Children with Down syndrome often have better outcomes when treated with specific regimens, contrary to this option.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell's Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Bell's Palsy is a condition that affects the facial nerve, leading to weakness or paralysis of the facial muscles. One common complication of Bell's Palsy is the inability to fully close the affected eye, which can result in corneal exposure and dryness. Lubricating eye drops help prevent dryness and protect the cornea from damage due to inadequate eye closure. Using lubricating eye drops regularly can help maintain the eye's moisture and prevent potential complications such as corneal abrasions and infections, which are common in patients with Bell's Palsy. Megavitamin therapy, application of ice, and elastic bandages are not typically indicated for preventing complications in patients with Bell's Palsy.
A nurse in the emergency department is assessing a 5-year-old child with symptoms of pneumonia and a fever of 102° F. Which intervention can the nurse implement to promote a sense of control for the child?
- A. None; this is an emergency and the child should not participate in care.
- B. Allow the child to hold the digital thermometer while taking the child's blood pressure.
- C. Ask the child if it is OK to take a temperature in the ear.
- D. Have parents wait in the waiting room.
Correct Answer: C
Rationale: Involving the child in decision-making and asking for their permission before performing a procedure promotes a sense of control and autonomy. By asking the child if it is OK to take the temperature in the ear, the nurse respects the child's preferences and helps them feel more empowered in the situation. This fosters a positive therapeutic relationship and can help reduce the child's anxiety during the medical assessment.
To meet the emotional needs of a 10-year-old patient who is dying, the most appropriate nursing action is to:
- A. answer questions honestly and frankly.
- B. avoid interruptions by coordinating nursing actions.
- C. encourage the patient to write in a journal.
- D. provide opportunities for the patient to interact with children of the same age.
Correct Answer: A
Rationale: Answering questions honestly and frankly helps build trust and provides clarity for the child during this difficult time.