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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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The nurse is assisting with the removal of a client’s chest tube. Which of the following actions should the nurse take? Select all that apply.
- A. Ensure the client is given an analgesic 30-60 minutes before tube removal
- B. Instruct the client to breathe in, hold it, and bear down while the tube is being removed
- C. Place the client in the Trendelenburg position
- D. Prepare a sterile airtight petroleum jelly gauze dressing
- E. Provide the health care provider with sterile suture removal equipment
Correct Answer: A,B,D,E
Rationale: Analgesics reduce pain, Valsalva maneuver (bear down) prevents air entry, petroleum gauze seals the site, and suture equipment is needed. Trendelenburg is not indicated for chest tube removal.
The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in
- A. Calcium
- B. Fiber
- C. Sodium
- D. Carbohydrate
Correct Answer: C
Rationale: Sodium. The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.
A diabetic client asks the nurse why she should use a diaphragm as a method of contraception instead of birth control pills. The best explanation for the use of a diaphragm is:
- A. A diaphragm will best prevent pregnancy because oral contraceptives are rendered ineffective by increased glucose levels.
- B. A diaphragm is a noninvasive method of contraception that will not alter the blood glucose levels.
- C. A diaphragm will provide intrauterine contraception by preventing implantation of the embryo.
- D. A diaphragm is a noninvasive method of contraception that prevents the egg from being released from the ovary.
Correct Answer: B
Rationale: A diaphragm does not affect blood glucose, unlike oral contraceptives, which can alter glycemic control. Oral contraceptives are not ineffective due to glucose levels, diaphragms do not prevent implantation or ovulation, and they are not intrauterine.
The women’s health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?
- A. Client reports heavy menstrual cycles
- B. History of breast cancer in maternal aunt
- C. History of deep venous thrombosis
- D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m^2
Correct Answer: C
Rationale: Deep venous thrombosis is a contraindication for estrogen-containing contraceptives like the patch due to increased clotting risk. Heavy menses, family history of breast cancer, and obesity are less critical.
A client on the oncology unit is to receive heparin sodium 5 units per kilogram of body weight by subcutaneous route every 4 hours. The client weighs 105.6 lbs. How many units should the client receive in a 24-hour period?
- A. 800
- B. 1080
- C. 1440
- D. 1960
Correct Answer: C
Rationale: The client weighs 48 kg and should receive 5 units/kg, or 240 units every 4 hours. This would be 1440 units in 24 hours. The answers in A, B, and D are incorrect calculations.