Nokea
The nurse observes a novice nurse caring for a client experiencing status epilepticus. Which action by the novice nurse requires immediate intervention?
- A. Prepares to administer intravenous valproate.
- B. Place the client in a lateral position.
- C. Activates the rapid response team (RRT).
- D. Loosens any restrictive clothing.
Correct Answer: A
Rationale: Valproate is not a first-line treatment for status epilepticus; benzodiazepines like lorazepam are preferred.
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The nurse is caring for an older adult brought to the emergency department with concerns about delirium. Which of the following findings would support a diagnosis of delirium?
- A. Abrupt onset
- B. Change in psychomotor activity
- C. Irreversible
- D. Progressively worsens
- E. Decreased attention and awareness
- F. Fluctuating level of consciousness
Correct Answer: A,B,E,F
Rationale: Delirium is characterized by abrupt onset, changes in psychomotor activity, decreased attention, and fluctuating consciousness. It is reversible, unlike dementia.
The following scenario applies to the next 1 items
The intensive care unit nurse has completed the assessment of a client
Item 1 of 1
Nurses' Notes
Progress Notes Orders
Day 2
1445: Physician at the bedside. The client is sedated, receiving mechanical ventilation via the #8 endotracheal tube. Current ventilator settings: assist control; rate 12/minute; tidal volume 450 mL; FiO 2 100%; positive end-expiratory pressure (PEEP) 5 cm H20. Intraventricular catheter present and zeroed and calibrated. No purposeful movement, and pupils were 3 mm equally round and sluggish to light. No abnormal posturing. + gag reflex; + corneal reflex. Lung sounds clear bilaterally, and the chest rises and falls synchronously with the ventilator. Peripheral pulses 2+ and S1 and S2 heart tones. Normoactive bowel sounds in all quadrants, no abdominal distention. Skin warm and dry. Indwelling urinary catheter patent and draining clear, concentrated urine. The client is currently positioned in a semi-Fowler position.
The nurse reviews the physician's orders
Click to specify if the order is indicated or requires follow-up with the physician:
- A. 0.45% saline infusion
- B. increase PEEP to 15 cm H20
- C. enoxaparin subcutaneously
- D. levetiracetam intravenous piggy-back
- E. pneumatic compression devices to the lower extremities
- F. repeated computed tomography (CT) scan
Correct Answer: B,B,B,A,A,A
Rationale: Hypotonic saline (0.45%) may worsen cerebral edema in brain injury; isotonic saline is preferred.
After a patient experiences a motor vehicle accident (MVA) and suffers a complete spinal cord injury to L3, the nurses would assess for loss of motor function in the:
- A. Abdomen
- B. Arms
- C. Legs
- D. Chest
Correct Answer: C
Rationale: L3 spinal cord injury affects lower extremity motor function, leading to leg paralysis.
The nurse has administered the first dose of prescribed rivastigmine to a client with Alzheimer's disease. Which clinical data is necessary to monitor while this client takes this medication?
- A. Glucose
- B. Weight
- C. Creatinine
- D. Hemoglobin and hematocrit
Correct Answer: B
Rationale: Rivastigmine, a cholinesterase inhibitor, can cause gastrointestinal side effects such as nausea, vomiting, and weight loss. Monitoring weight is essential to assess for significant weight loss, which can impact the client's health. Glucose, creatinine, and hemoglobin/hematocrit are not typically affected by rivastigmine.
The nurse is assessing a client who is postoperative following a hypophysectomy. Which of the following findings should the nurse report to the primary healthcare provider (PHCP) immediately?
- A. Client reports a decreased smell
- B. No bowel movement in two days
- C. Foul-smelling breath
- D. Hourly urine output of 125 mL
Correct Answer: D
Rationale: High urine output suggests diabetes insipidus, a serious complication post-hypophysectomy.