Nokea
The nurse is caring for a client with a history of seizures. The client begins to experience a tonic-clonic seizure. Which of the following actions should the nurse take FIRST?
- A. Restrain the client to prevent injury.
- B. Place a tongue depressor in the client's mouth.
- C. Turn the client to the side.
- D. Administer lorazepam (Ativan) IV.
Correct Answer: C
Rationale: turning the client to the side helps maintain a patent airway and prevents aspiration during a seizure
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A four-week-old infant with symptoms of pyloric stenosis is brought to the outpatient clinic by his mother. Which of the following statements would the nurse expect the mother to make about her son's symptoms?
- A. My son's bowel movements have turned black and sticky.
- B. I really have to encourage my son to suck the bottle.
- C. My son is fussy and seems hungry all the time.
- D. My son spits up green liquid after feeding.
Correct Answer: C
Rationale: becomes lethargic, dehydrated, and malnourished
The mother of an eight-month-old infant prepares to take her child home after treatment for bacterial meningitis. The mother confides to the nurse that she is afraid that her child will have brain damage as a result of his illness. Which of the following is the BEST response by the nurse?
- A. Trust your doctors. They are excellent pediatricians and will know what to look for.
- B. There is a 20% incidence of residual brain damage after this type of illness, but the odds are in your favor.
- C. It is an unlikely possibility, but if your child doesn't develop normally, your pediatrician will help you with any problems.
- D. You feel guilty about your son's illness, and that's understandable. You will feel better after you get home.
Correct Answer: C
Rationale: if treated early, good prognosis; may be complications and long-term effects (seizure disorders, hydrocephalus, impaired intelligence, visual and hearing defects), therapeutic response
The nurse performs a routine IV tubing change on a 55-year-old woman with a central line. Fifteen minutes later, the nurse reenters the patient's room to find her cyanotic, short of breath, and complaining of pain. Her vital signs are BP 84/62, pulse 112, respirations 18.
What is the FIRST action the nurse should take?
- A. Call the physician to report the patient's symptoms.
- B. Lower the head of the bed and place the patient on her left side.
- C. Place the patient in high Fowler's position.
- D. Start oxygen at 4 L/min via nasal cannula.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) second action, first should respond to potential problem of emboli (2) correct-air will rise to right atrium, minimizes chance of air bubbles entering cerebral circulation (3) never done with shock, trapped air could travel to pulmonary circulation (4) not first action
The nurse is assessing a client with a diagnosis of detached retina. Which of the following observations would support this diagnosis?
- A. Loss of acuity in the peripheral visual field.
- B. Increased lacrimation, blurred vision.
- C. Conjunctivitis, dilated pupils bilaterally.
- D. Photophobia, loss of a portion of the visual field.
Correct Answer: D
Rationale: bright flashes of light and client stating that portion of visual field is dark are classic symptoms
A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems