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The nurse is caring for a client with a history of seizures. Which precaution should be implemented?
- A. Keep the bed in the highest position.
- B. Ensure suction equipment is at the bedside.
- C. Allow the client to ambulate without assistance.
- D. Remove all padded side rails.
Correct Answer: B
Rationale: Suction equipment is essential to maintain airway patency during a seizure, a critical safety precaution.
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A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
A worried mother confides in the nurse that she wants to change physicians because her infant is not getting better. The best response by the nurse is which of the following?
- A. This doctor has been on our staff for 20 years.'
- B. I know you are worried, but the doctor has an excellent reputation.'
- C. You always have an option to change. Tell me about your concerns.'
- D. I take my own children to this doctor.'
Correct Answer: C
Rationale: Acknowledging the mother's concerns and offering to discuss them respects her autonomy and opens a dialogue to address specific issues, potentially resolving misunderstandings or facilitating a change if needed.
The nurse is teaching a client with a new colostomy about dietary choices. Which of the following foods should the nurse recommend to prevent odor and gas?
- A. Yogurt.
- B. Broccoli.
- C. Cabbage.
- D. Beans.
Correct Answer: A
Rationale: Yogurt contains probiotics that can reduce gas and odor in colostomy output, unlike broccoli, cabbage, or beans.
You are running a caregiver support group for those who are caring for a person with impaired cognition related to Alzheimer's disease. You are planning a session on the stages of Alzheimer's disease, its progression and some useful helpful tips for these participating care givers. Which of the following elements should you include in this session?
- A. According to the Global Deterioration Scale, clients in the first stage of Alzheimer's disease tend to cover up their failing abilities
- B. According to the Reisberg Scale, clients in the first stage of Alzheimer's disease tend to cover up their failing abilities
- C. According to the Global Deterioration Scale, clients in the third stage of Alzheimer's disease tend to cover up their failing abilities
- D. According to the Reisberg Scale, clients in the fourth stage of Alzheimer's disease tend to cover up their failing abilities
Correct Answer: B
Rationale: The Reisberg Scale (Global Deterioration Scale) indicates that in the first stage, individuals with Alzheimer's may cover up their failing abilities, which is an important point to include for caregivers to understand early disease behaviors.
A 7-year-old child is admitted to the hospital with acute rheumatic fever. When discussing long-term care for the child with the parents, the nurse should teach them that a necessary part of this care is:
- A. Physical therapy.
- B. Antibiotic therapy.
- C. Psychological therapy.
- D. Anti-inflammatory therapy.
Correct Answer: B
Rationale: Antibiotic therapy is essential for acute rheumatic fever to eradicate streptococcal infection and prevent recurrence, which is critical for long-term management.