Nokea
The nurse is caring for a client who had a seizure 10 minutes ago. The client is now confused and reports a headache. Which of the following phases of seizure activity should the nurse recognize the client is experiencing?
- A. Ictal phase
- B. Aural phase
- C. Postictal phase
- D. Prodromal phase
Correct Answer: C
Rationale: The postictal phase follows a seizure, characterized by confusion and headache as the brain recovers. Ictal is the seizure itself, aural involves pre-seizure sensations, and prodromal is vague premonitory symptoms.
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A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: This client is receiving secondary prevention. The current focus of health care is on preventive care. Leavell and Clark (1965) described the three levels of preventive care as primary, secondary, and tertiary. Secondary preventive care focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems.
The nurse enters a client’s room just as the unlicensed assistive personnel (UAP) is completing a bath and placing thigh-high anti-embolism stockings on the client. Which situation would cause the nurse to intervene?
- A. UAP applies the anti-embolism stockings while maintaining the client in supine position
- B. UAP carefully smoothes out any wrinkles over the length of the stockings
- C. UAP checks that the toe opening of the stockings is located on the plantar side of the foot
- D. UAP rolls down and folds over the excess material at the top of the stockings
Correct Answer: D
Rationale: Rolling and folding the stockings creates pressure points, risking skin breakdown and poor circulation. Supine application and correct toe opening placement are appropriate.
The nurse is caring for an elderly woman who had surgery on her right foot yesterday. The woman had a broken left arm three months ago and has osteoarthritis. Which type of assistive device will probably be most appropriate for this client?
- A. Quad cane
- B. Crutches
- C. Walker
- D. Tripod cane
Correct Answer: C
Rationale: A walker provides maximum stability for an elderly woman with recent foot surgery, prior arm injury, and osteoarthritis, ensuring safe ambulation.
The nurse is evaluating the effectiveness of the medication regimen for a client with chronic kidney disease who is receiving sodium polystyrene sulfonate. It would indicate that the medication regimen has been effective if the client’s most recent laboratory test results indicate
- A. an increase in the serum calcium level
- B. an increase in the serum creatinine level
- C. a decrease in the serum potassium level
- D. a decrease in the serum phosphate level
Correct Answer: C
Rationale: Sodium polystyrene sulfonate treats hyperkalemia in chronic kidney disease by exchanging sodium for potassium in the gut, so a decreased potassium level indicates effectiveness. Calcium levels are not directly affected, and rising creatinine indicates worsening kidney function.
The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?
- A. Anticipate the use of clean technique during the circumcision
- B. Apply a snug-fitting diaper following the procedure
- C. Offer a bottle during the procedure
- D. Wrap the newborn’s upper body in a blanket for the circumcision
Correct Answer: D
Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.