Nokea
What intervention should the nurse implement while a client is having a grand mal seizure?
- A. Open the jaw and place a bite block between the teeth
- B. Try to place the client on his side
- C. Restrain the client to prevent injury
- D. Place pillows around the client
Correct Answer: B
Rationale: During a grand mal seizure, the client is at risk of injury due to severe, involuntary muscle spasms and contractions. It is crucial for the nurse to avoid restraining the client or inserting objects into their mouth, as these actions may lead to further harm. Placing the client on their side can help facilitate the drainage of oral secretions and assist in maintaining an open airway, reducing the risk of aspiration. Restraint should be avoided as it can exacerbate muscle contractions and increase the risk of injury. Placing pillows around the client may not provide adequate support or protection during the seizure, making it a less effective intervention compared to positioning the client on their side.
You may also like to solve these questions
A 34-year-old female has recently been diagnosed with an autoimmune disease. She has also recently discovered that she is pregnant. Which of the following is the only immunoglobulin that will provide protection to the fetus in the womb?
- A. IgA
- B. IgD
- C. IgE
- D. IgG
Correct Answer: D
Rationale: IgG is the only immunoglobulin that can cross the placental barrier, providing passive immunity to the fetus. About 70-80% of the immunoglobulins in the blood are IgG. Specific IgG antibodies are generated after an initial exposure to an antigen, offering long-term protection against microorganisms. IgG antibodies are critical for protecting the fetus as they can be rapidly reproduced upon re-exposure to the same antigen. IgA is primarily found in mucosal areas, IgD is involved in antigen recognition, and IgE is associated with allergic reactions, but they do not provide the same level of protection to the fetus as IgG.
A 33-year-old male client with heart failure has been taking furosemide for the past week. Which of the following assessment cues below may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: The correct answer is 'Decreased appetite.' Furosemide is a loop diuretic used for conditions like heart failure, where it helps reduce fluid retention. One common side effect of furosemide is hypokalemia, which can lead to decreased appetite among other symptoms. Hypokalemia is a low level of potassium in the blood, and its signs and symptoms include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, dysrhythmias, reduced urine osmolality, and altered level of consciousness. Weight gain and ankle edema are actually expected outcomes of furosemide therapy due to its diuretic effect, which helps reduce edema and fluid overload. Gastric irritability is a nonspecific symptom that is not typically associated with furosemide use. Therefore, a decreased appetite is a key indicator of a potential negative side effect when assessing a client on furosemide therapy.
Which of the following conditions most commonly causes acute glomerulonephritis?
- A. A congenital condition leading to renal dysfunction.
- B. Prior infection with group A Streptococcus within the past 10-14 days.
- C. Viral infection of the glomeruli.
- D. Nephrotic syndrome.
Correct Answer: B
Rationale: Acute glomerulonephritis is most commonly caused by the immune response to a prior
upper respiratory infection with group A Streptococcus. Glomerular inflammation occurs
about 10-14 days after the infection, resulting in scant, dark urine and retention of body
fluid. Periorbital edema and hypertension are common signs at diagnosis.
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His wife states he fell down the stairs two (2) hours ago. The nurse should
- A. Place a call to the client's healthcare provider for instructions
- B. Send him to the emergency room for evaluation
- C. Reassure the client's wife that the symptoms are transient
- D. Instruct the client's wife to call the doctor if his symptoms become worse
Correct Answer: B
Rationale: In this scenario, the client is presenting with concerning symptoms of lethargy and confusion after a fall. These symptoms could indicate a serious underlying issue, such as a head injury or internal bleeding. The nurse's priority is to ensure the client receives immediate evaluation and treatment to prevent any further harm. Option B is the correct choice as it emphasizes the urgency of the situation. Choices A, C, and D are incorrect because they do not address the critical nature of the client's condition. Contacting the healthcare provider, reassuring the wife, or waiting for symptoms to worsen could delay necessary medical intervention.
A child weighing 30 kg arrives at the clinic with diffuse itching as the result of an allergic reaction to an insect bite. Diphenhydramine (Benadryl) 25 mg 3 times a day is prescribed. The correct pediatric dose is 5 mg/kg/day. Which of the following best describes the prescribed drug dose?
- A. It is the correct dose
- B. The dose is too low
- C. The dose is too high
- D. The dose should be increased or decreased, depending on the symptoms
Correct Answer: B
Rationale: The correct pediatric dose of diphenhydramine is 5 mg/kg/day. This child weighs 30 kg, so the calculated dose would be 5 mg/kg x 30 kg = 150 mg/day. Since the prescription is for 25 mg 3 times a day, the total daily dose is 25 mg x 3 = 75 mg/day, which is lower than the calculated dose of 150 mg/day. Therefore, the prescribed dose of 25 mg 3 times a day is too low for this child. The dose should be adjusted to meet the correct dosage of 150 mg/day, which would be 50 mg 3 times a day. It is important not to titrate the dosage based on symptoms without consulting a physician, as this can lead to inappropriate medication administration.