Nokea
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.
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The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?
- A. BP=140/60
- B. Pulse=100
- C. BP=114/68
- D. Pulse=60
Correct Answer: B
Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.
The nurse is caring for a 2-year-old client who has iron deficiency anemia. The nurse should recognize that this condition is most likely the result of
- A. impaired iron transfer from the mother
- B. excessive intake of meat products
- C. excessive intake of cow's milk
- D. gastrointestinal blood loss
Correct Answer: C
Rationale: Excessive cow's milk intake in toddlers can lead to iron deficiency anemia due to low iron content and potential for gastrointestinal irritation.
In the past 12-month period, a man has been arrested twice for driving while intoxicated. He is able to perform his activities of daily living without the use of alcohol and restricts his drinking to weekends. This client meets the criteria for which of the following?
- A. Alcohol withdrawal syndrome
- B. Bad judgment syndrome
- C. Substance abuse
- D. Substance dependence
Correct Answer: C
Rationale: Repeated legal issues from weekend drinking indicate substance abuse, as it causes significant impairment without daily dependence.
The health care provider has prescribed spironolactone to be given in addition to hydrochlorothiazide to a client with hypertension. Which finding by the nurse indicates that the spironolactone is having the desired effect?
- A. Blood glucose of 95 mg/dL (5.3 mmol/L)
- B. Potassium level of 4.2 mEq/L (4.2 mmol/L)
- C. Reduction in dizziness
- D. Sodium level of 138 mEq/L (138 mmol/L)
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic, so a normal potassium level indicates it is counteracting the potassium loss from hydrochlorothiazide.
An adult who is scheduled for surgery tomorrow asks the nurse to arrange for his Healing Touch practitioner to give him healing touch treatments after surgery. The client's daughter who hears the request asks the nurse to explain how Healing Touch can help her father. What information should the nurse include in the response?
- A. Healing Touch makes use of the power of suggestion and can help the person feel more comfortable.
- B. No one really knows how it works, but if a person really wants it, it certainly will not hurt.
- C. The Healing Touch practitioner works within the energy field around the person to facilitate healing and pain relief.
- D. Healing Touch is similar to acupuncture except that pressure is used instead of needles.
Correct Answer: C
Rationale: Healing Touch involves manipulating the energy field to promote healing and pain relief, a recognized complementary therapy.