Nokea
When implementing seizure precautions, which nursing action is most appropriate?
- A. Move the client to a room closer to the nurses' station.
- B. Serve the client's food in paper and plastic containers.
- C. Maintain the client's bed in the lowest position.
- D. Ensure that soft limb restraints are applied to upper extremities.
Correct Answer: C
Rationale: Maintaining the bed in the lowest position minimizes the risk of injury from falls during a seizure.
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The nurse is admitting a client with the diagnosis of Parkinson’s disease. Which assessment data support this diagnosis?
- A. Crackles in the upper lung fields and jugular vein distention.
- B. Muscle weakness in the upper extremities and ptosis.
- C. Exaggerated arm swinging and scanning speech.
- D. Masklike facies and a shuffling gait.
Correct Answer: D
Rationale: Masklike facies and shuffling gait (D) are hallmark signs of Parkinson’s due to bradykinesia and rigidity. Crackles and JVD (A) suggest heart failure, weakness and ptosis (B) indicate myasthenia gravis, and exaggerated arm swinging (C) is opposite to Parkinson’s.
The client is in status epilepticus. Which interventions, if prescribed, should be included in this client's immediate treatment? Select all that apply.
- A. Administer dexamethasone intravenously.
- B. Give oxygen and prepare for endotracheal intubation.
- C. Obtain a defibrillator and prepare to use it immediately.
- D. Remove nearby objects to protect the client from injury.
- E. Administer lorazepam intravenously STAT.
Correct Answer: B,D,E
Rationale: Anticonvulsant medications such as phenytoin (Dilantin), and not anti-inflammatory medications such as dexamethasone (Decadron), are administered IV to control seizure activity. Status epilepticus is a medical emergency. The client is at risk for brain hypoxia and permanent brain damage. The client needs additional oxygen, and intubation will secure the airway. Defibrillation is treatment for ventricular fibrillation, a lethal heart dysrhythmia. Care is taken to protect the client from injury during the seizure. Either lorazepam (Ativan) or diazepam (Valium) is administered initially to terminate the seizure because they can be administered more rapidly than phenytoin.
The client with ALS is admitted to the medical unit with shortness of breath, dyspnea, and respiratory complications. Which intervention should the nurse implement first?
- A. Elevate the head of the bed 30 degrees.
- B. Administer oxygen via nasal cannula.
- C. Assess the client’s lung sounds.
- D. Obtain a pulse oximeter reading.
Correct Answer: B
Rationale: Dyspnea in ALS indicates respiratory distress. Administering oxygen (B) addresses hypoxia immediately. Elevating HOB (A), assessing lung sounds (C), and pulse oximetry (D) follow to support respiratory status.
On the basis of the factors that cause the client to experience paroxysmal pain, which intervention is most appropriate to include in this client's care plan?
- A. Direct a fan toward the client's face.
- B. Avoid care that involves touching the client's face.
- C. Apply ice packs to the client's face.
- D. Apply warm facial compresses for pain.
Correct Answer: B
Rationale: Avoiding facial touch minimizes triggering paroxysmal pain in trigeminal neuralgia, which is sensitive to tactile stimuli.
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.