Nokea
The nurse is preparing to teach a client about phenytoin sodium (Dilantin). Which fact would be most important to teach the client regarding why the drug should not be stopped suddenly?
- A. Physical dependence can develop over time.
- B. Status epilepticus can develop.
- C. A hypoglycemic reaction can develop.
- D. Heart block can develop.
Correct Answer: B
Rationale: Abruptly stopping phenytoin can precipitate status epilepticus, a life-threatening condition, due to loss of seizure control.
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Which statement is true regarding balanced skeletal traction? Balanced skeletal traction:
- A. Utilizes a Steinman pin
- B. Requires that both legs be secured
- C. Utilizes Kirschner wires
- D. Is used primarily to heal the fractured hips
Correct Answer: A
Rationale: Balanced skeletal traction commonly uses a Steinman pin to stabilize fractures.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
For which of the following reasons would the nurse use the Braden Scale to assess a client?
- A. To determine if the client is suffering from delirium.
- B. To determine if the client is at risk for developing pressure sores.
- C. To determine if the client is at risk for falls.
- D. To determine if the client is at risk for substance abuse.
Correct Answer: B
Rationale: The Braden Scale assesses risk for pressure sores (B) by evaluating factors like mobility and skin moisture. It is not used for delirium (A), falls (C), or substance abuse (D).
The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations?
- A. The staff maintains a calm manner when interacting with the client.
- B. The staff attends to client's physical needs as necessary.
- C. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety.
- D. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.
Correct Answer: C
Rationale: in this level of anxiety, client is unable to process thoughts and feelings for problem solving
The school nurse assessed and referred a 14-year-old with scoliosis. An 18° curvature of the spine was diagnosed. Which treatment plan would the nurse expect?
- A. Application of a Milwaukee brace
- B. Electrical stimulation to the outward side of the curve
- C. Re-evaluation, with no treatment at this time
- D. Surgical realignment of the spine
Correct Answer: C
Rationale: An 18° scoliosis curvature is mild and typically monitored with re-evaluation, as bracing or surgery is reserved for curvatures >25° or >40°, respectively.