Nokea
The nurse enters the room as the client is beginning to have a tonic-clonic seizure. What action should the nurse implement first?
- A. Note the first thing the client does in the seizure.
- B. Assess the size of the client’s pupils.
- C. Determine if the client is incontinent of urine or stool.
- D. Provide the client with privacy during the seizure.
Correct Answer: A
Rationale: Noting the first action (A) helps identify the seizure type and focus, aiding diagnosis and treatment. Pupil size (B), incontinence (C), and privacy (D) are secondary to ensuring safety and documenting the event.
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A hospitalized client diagnosed with seizures has a vagus nerve stimulation (VNS) device implanted. The nurse determines that the VNS is working properly when making which observation?
- A. It stimulated a heartbeat when bradycardia occurred during a seizure.
- B. It defibrillated a lethal rhythm that occurred during the client’s seizure.
- C. The client activates the VNS device to stop a seizure from occurring.
- D. The client activates the device at seizure onset to prevent aspiration.
Correct Answer: C
Rationale: A VNS device does not stimulate the heart to beat as a pacemaker. A VNS device does not defibrillate the heart as an implantable cardioverter/defibrillator does. A VNS is a medical device that is implanted in the chest and stimulates the vagus nerve to control seizures unresponsive to medical treatment. Clients who experience auras before a seizure use a magnet to activate the VNS to stop the seizure. The device does not have an effect on the airway or secretions.
When the nurse performs a physical assessment, which finding is most indicative of the client's disorder?
- A. Quivering eye movement
- B. Muscle spasms in the lower extremities
- C. Loss of motor function on the affected side
- D. Unilateral facial paralysis
Correct Answer: D
Rationale: Unilateral facial paralysis is the hallmark sign of Bell's palsy, caused by inflammation of cranial nerve VII.
The client comes to the clinic and reports a sudden drooping of the left side of the face and complains of pain in that area. The nurse notes that the client cannot wrinkle the forehead or close the left eye. Which condition should the nurse suspect?
- A. Bell's palsy.
- B. Right-sided stroke.
- C. Tetany.
- D. Mononeuropathy.
Correct Answer: A
Rationale: Bell’s palsy (A) causes unilateral facial drooping, inability to wrinkle the forehead, and eye closure issues due to facial nerve paralysis. Right-sided stroke (B) affects the opposite side, tetany (C) involves muscle spasms, and mononeuropathy (D) is less specific.
What nursing approach is best when managing the care of a client with dementia who insists on carrying a purse at all times?
- A. Ask the client where the purse can be stored.
- B. Take the purse and give it to the family.
- C. Inform the client that the purse may become lost.
- D. Find out why the client feels the need for a purse.
Correct Answer: D
Rationale: Understanding the client's need to carry a purse addresses emotional or security needs, improving care and reducing distress.
Which diagnostic evaluation tool would the nurse use to assess the client’s cognitive functioning? Select all that apply.
- A. The Geriatric Depression Scale (GDS).
- B. The St. Louis University Mental Status (SLUMS) scale.
- C. The Mini-Mental Status Examination (MMSE) scale.
- D. The Manic Depression vs Elderly Depression (MDED) scale.
- E. The Functional Independence Measurement Scale (FIMS).
Correct Answer: B,C
Rationale: SLUMS (B) and MMSE (C) directly assess cognitive functions like memory and orientation. GDS (A) assesses depression, MDED (D) is not standard, and FIMS (E) measures physical function.