Nokea
The unlicensed assistive personnel (UAP) is caring for a client who is having a seizure. Which action by the UAP would warrant immediate intervention by the nurse?
- A. The assistant attempts to insert an oral airway.
- B. The assistant turns the client on the right side.
- C. The assistant has all the side rails padded and up.
- D. The assistant does not leave the client's bedside.
Correct Answer: A
Rationale: Inserting an oral airway during a seizure (A) risks injury and is contraindicated. Turning to the side (B), padding rails (C), and staying with the client (D) are appropriate.
You may also like to solve these questions
The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which preoperative instruction is important for the nurse to teach?
- A. There will be a large turban dressing around the skull after surgery.
- B. The client will not be able to eat for four (4) or five (5) days postop.
- C. The client should not blow the nose for two (2) weeks after surgery.
- D. The client will have to lie flat for 24 hours following the surgery.
Correct Answer: C
Rationale: Blowing the nose (C) risks disrupting the surgical site and causing CSF leaks after transsphenoidal surgery. Turban dressings (A) are not used, eating resumes sooner (B), and flat positioning (D) is not required.
Which intervention has the highest priority for the client in the emergency department who has been in a motorcycle collision with an automobile and has a fractured left leg?
- A. Assessing the neurological status.
- B. Immobilizing the fractured leg.
- C. Monitoring the client's output.
- D. Starting an 18-gauge saline lock.
Correct Answer: A
Rationale: Trauma patients require a primary survey, prioritizing neurological status (A) to detect head injuries, which are life-threatening. Immobilizing the leg (B), monitoring output (C), and IV access (D) follow.
Which nursing intervention is most effective in helping a client with aphasia communicate?
- A. Speak loudly and clearly to the client.
- B. Use simple pictures or a communication board.
- C. Ask the client to write responses to questions.
- D. Encourage the client to repeat words after the nurse.
Correct Answer: B
Rationale: A communication board or pictures aids communication for clients with aphasia by providing visual cues to express needs.
The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement?
- A. Refer the child for genetic counseling as soon as possible.
- B. Teach the child to use a warming tray under the food during meals.
- C. Discuss the importance of not abandoning the parent.
- D. Allow the child to talk about the fear of getting the disease.
Correct Answer: D
Rationale: Huntington’s has a 50% genetic risk. Allowing the child to express fears (D) addresses psychosocial needs therapeutically. Genetic counseling (A) is appropriate but secondary, warming trays (B) are irrelevant, and abandonment discussions (C) may guilt-trip.
The client diagnosed with Parkinson's disease is prescribed carbidopa/levodopa (Sinemet). Which intervention should the nurse implement prior to administering the medication?
- A. Discuss how to prevent orthostatic hypotension.
- B. Take the client's apical pulse for one (1) full minute.
- C. Inform the client that this medication is for short-term use.
- D. Tell the client to take the medication on an empty stomach.
Correct Answer: A
Rationale: Carbidopa/levodopa can cause orthostatic hypotension. Discussing prevention (A) ensures safety. Pulse (B) is not routine, the medication is long-term (C), and it can be taken with food (D) to reduce nausea.