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The nurse is talking with a client with a brain tumor who has a new prescription for levetiracetam. Which of the following statements would be appropriate for the nurse to make?
- A. The medication will prevent blood clots in your legs.
- B. The medication will decrease the size of your tumor.
- C. The medication helps prevent seizures from occurring.
- D. The medication helps decrease swelling around your tumor.
Correct Answer: C
Rationale: Levetiracetam is an anticonvulsant used to prevent seizures, a common complication in brain tumor patients.
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The nurse knows that a client with right-sided hemiplegia understands teaching regarding ambulation with a cane if she states:
- A. I will hold the cane in my right hand.
- B. I will advance the cane and the right leg together.
- C. I will be able to walk only by using a walker.
- D. I will hold the cane in my left hand.
Correct Answer: D
Rationale: For right-sided hemiplegia, the cane is held in the left hand to support the weaker right side. Holding it in the right hand or advancing it with the right leg is incorrect. A walker is not always necessary.
The nurse is teaching a group of women about health issues. Today's topic is food poisoning. Which statement indicates a need for further instruction?
- A. I always wash my hands after I put raw meat in to cook.'
- B. I should put foods away in the refrigerator immediately after meals.'
- C. I will wash my kitchen counters with a bleach solution after preparing raw meat.'
- D. Rare meat is okay to eat as long as it is eaten immediately after cooking.'
Correct Answer: D
Rationale: Rare meat poses a risk for foodborne pathogens like E. coli, even if eaten immediately. Other statements reflect proper food safety practices.
An adult who has been well controlled on phenytoin (Dilantin) reports having had several seizures recently. Which comment made by the client is probably related to seizure activities?
- A. I started exercising two weeks ago.'
- B. Last week I changed jobs.'
- C. I have been going to Happy Hour with my friends recently.'
- D. I started taking ibuprofen for achy joints a couple of weeks ago.'
Correct Answer: C
Rationale: Alcohol consumption (Happy Hour) can lower the seizure threshold, reducing phenytoin's effectiveness, likely causing seizures, unlike exercise, job changes, or ibuprofen.
A client in the medical-surgical unit has an indwelling urinary catheter. Which actions should the nurse implement to reduce the incidence of catheter-associated urinary tract infections? Select all that apply.
- A. Cleanse periurethral area with antiseptics every shift
- B. Ensure each client has a separate container to empty collection bag
- C. Keep catheter bag below the level of the bladder
- D. Routinely irrigate the catheter with antimicrobial solution
- E. Use sterile technique when collecting a urine specimen
Correct Answer: B,C,E
Rationale: Using a separate container prevents cross-contamination. Keeping the bag below the bladder prevents urine backflow, reducing infection risk. E: Sterile technique minimizes pathogen introduction during specimen collection. A is incorrect as routine antiseptic cleansing can disrupt natural flora, increasing infection risk. D is incorrect as routine irrigation is not recommended unless medically indicated, as it can introduce pathogens.
The nurse manager informs the nursing staff at morning report that the clinical nurse specialist will be conducting a research study on staff attitudes toward client care. All staff are invited to participate in the study if they wish. This affirms the ethical principle of
- A. Anonymity
- B. Beneficence
- C. Justice
- D. Autonomy
Correct Answer: D
Rationale: Autonomy. Individuals must be free to make independent decisions about participation in research without coercion from others.