Nokea
What is the most appropriate intervention for a client with a history of seizures?
- A. Administer antiepileptics
- B. Monitor vital signs
- C. Apply oxygen therapy
- D. Monitor ECG
Correct Answer: A
Rationale: The correct answer is A: Administer antiepileptics. This is the most appropriate intervention for a client with a history of seizures as antiepileptic medications help prevent or reduce the frequency of seizures. Monitoring vital signs (B) is important but does not directly address the underlying issue of seizures. Oxygen therapy (C) may be needed during a seizure but does not prevent future episodes. Monitoring ECG (D) may provide information on cardiac function but is not the primary intervention for seizures. Administering antiepileptics is essential for seizure management.
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What is the best nursing action for a client with a wound infection?
- A. Administer antibiotics
- B. Apply sterile dressing
- C. Monitor blood pressure
- D. Place the client in a sitting position
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. This is the best nursing action for a client with a wound infection because antibiotics are necessary to treat the infection at its source, targeting the bacteria causing the infection. Antibiotics help prevent the infection from spreading and promote healing.
Explanation of why other choices are incorrect:
B: Applying a sterile dressing is important for wound care but does not address the underlying infection.
C: Monitoring blood pressure is important for overall patient assessment but does not directly treat the wound infection.
D: Placing the client in a sitting position is not relevant to treating a wound infection.
What does the Health Insurance Portability and Accountability Act (HIPAA) regulate?
- A. Who will provide client care
- B. Privacy of information
- C. How insurance information is obtained
- D. Where a chart can be stored
Correct Answer: B
Rationale: The correct answer is B because HIPAA regulates the privacy and security of protected health information. This includes how healthcare providers, insurers, and other entities handle and safeguard patient information to ensure confidentiality. Choice A is incorrect as HIPAA does not dictate who provides client care. Choice C is incorrect as HIPAA focuses on the protection of health information, not how insurance information is obtained. Choice D is incorrect as HIPAA does not specify where a chart can be stored, but rather how the information within it is protected.
During a follow-up visit, the nurse discovers that the patient has not been taking his insulin regularly. The nurse asks, "Why haven't you taken your insulin?' Which of the following is an appropriate evaluation of this question?
- A. It may put the patient on the defensive.
- B. It is an innocent attempt to get information.
- C. It would have been better to discuss this with his wife.
- D. It is the best way to discover the reasons for his behaviour.
Correct Answer: A
Rationale: The correct answer is A because asking "Why haven't you taken your insulin?" may put the patient on the defensive. This question can come across as accusatory or judgmental, potentially making the patient feel guilty or defensive. It may hinder open communication and lead to a breakdown in the nurse-patient relationship.
Explanation of other choices:
B: While the question may be an attempt to gather information, it lacks sensitivity and may not promote open dialogue.
C: Involving the patient's wife without the patient's consent may breach confidentiality and undermine the patient's autonomy.
D: While asking the question may reveal reasons for the behavior, it is not the best approach as it can create a barrier to effective communication.
Which of the following actions is the nurse's priority when caring for a client with a suspected stroke?
- A. Assess the client's neurologic status
- B. Start an intravenous line and administer thrombolytics
- C. Monitor the client's ECG
- D. Provide emotional support
Correct Answer: C
Rationale: The correct answer is C: Monitor the client's ECG. This is the priority because it helps in detecting any cardiac abnormalities or arrhythmias which are common in stroke patients. Assessing neurologic status (A) is important but monitoring the ECG takes precedence. Starting an IV line and administering thrombolytics (B) should be done as per protocol but is not the immediate priority. Providing emotional support (D) is important, but ensuring the client's cardiac status is stable is crucial in the acute phase of stroke.
What is the best intervention for a client who is vomiting after surgery?
- A. Administer antiemetics
- B. Place the client in a supine position
- C. Encourage deep breathing
- D. Administer morphine
Correct Answer: D
Rationale: The correct answer is D: Administer morphine. The rationale is that vomiting after surgery can be a side effect of pain medication such as morphine. By administering morphine, the pain is reduced, which can help alleviate the vomiting. This intervention targets the root cause of the vomiting.
Other choices are incorrect because:
A: Administering antiemetics may help with nausea but does not address the underlying cause of vomiting.
B: Placing the client in a supine position may worsen vomiting due to increased abdominal pressure.
C: Encouraging deep breathing may help with relaxation but does not directly address the vomiting caused by pain.