Nokea
The nurse is caring for a client with a history of epilepsy.
- A. Which precaution is most important for a client with epilepsy?
- B. Keep the bed in the lowest position.
- C. Restrict all visitors to reduce stress.
- D. Administer oxygen during seizures.
- E. Place a padded tongue blade at the bedside.
Correct Answer: A
Rationale: Keeping the bed in the lowest position reduces fall risk during seizures. Visitors are not restricted, oxygen is not routine, and tongue blades are contraindicated.
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The nurse is caring for a client with a history of peptic ulcer disease who is receiving omeprazole (Prilosec) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a headache once in a while.
- B. I feel bloated after meals.
- C. I have black, tarry stools.
- D. I take my medication with breakfast.
Correct Answer: C
Rationale: Black, tarry stools suggest gastroinTest inal bleeding, a serious complication in peptic ulcer disease requiring immediate evaluation. Options A, B, and D are less concerning: headaches are nonspecific, bloating is common, and taking omeprazole with food is acceptable.
A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. Which of the following should be included in the patient's plan of care?
- A. Encourage client to shake head in response to questions.
- B. Speak in a loud voice during interactions.
- C. Speak using phrases and short sentences.
- D. Encourage the use of radio to stimulate the client.
Correct Answer: C
Rationale: will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions
The nurse is caring for a client with deep vein thrombosis (thrombophlebitis) of the left leg. Which of the following would be an appropriate nursing goal for this client?
- A. Decrease inflammatory response in the affected extremity and prevent embolus formation.
- B. Increase peripheral circulation and oxygenation of the affected extremity.
- C. Prepare the client and family for anticipated vascular surgery on the affected extremity.
- D. Prevent hypoxia associated with the development of a pulmonary embolus.
Correct Answer: A
Rationale: important to prevent the complication of pulmonary embolism in clients at high risk
The nurse is teaching a client with a new diagnosis of osteoporosis about calcitonin (Miacalcin). Which of the following statements by the client indicates a need for further teaching?
- A. I should report nasal irritation to my doctor.
- B. I should take this medication at bedtime.
- C. I should alternate nostrils when using the nasal spray.
- D. I should stop this medication if my bone density improves.
Correct Answer: D
Rationale: Stopping calcitonin when bone density improves is incorrect, as osteoporosis often requires ongoing treatment to maintain bone health. Options A, B, and C are correct: nasal irritation is a side effect, bedtime dosing is standard, and alternating nostrils prevents irritation.
The daughter of a 70-year-old patient with cancer asks the nurse, 'Do you believe in euthanasia?' Which of the following responses by the nurse is BEST?
- A. I think that each person has to decide this issue for herself.
- B. My religion is opposed to euthanasia.
- C. What are your thoughts about euthanasia?
- D. Did you see the TV program about euthanasia last night?
Correct Answer: C
Rationale: open-ended question, allows client to verbalize