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When providing care for an unconscious client who has seizures, which nursing intervention is most essential?
- A. Ensure oral suction is available.
- B. Maintain the client in a semi-Fowler's position.
- C. Provide frequent mouth care.
- D. Keep the room at a comfortable temperature.
Correct Answer: A
Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.
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Which client is at greatest risk for coronary artery disease?
- A. A 32-year-old female with mitral valve prolapse who quit smoking 10 years ago.
- B. A 43-year-old male with a family history of CAD and a cholesterol level of 158 (8.8 mmol/L).
- C. A 56-year-old male with an HDL of 60 (3.3 mmol/L) who takes atorvastatin.
- D. A 65-year-old female who is obese with an LDL of 188 (10.4 mmol/L).
Correct Answer: D
Rationale: The 65-year-old female who is obese with a high LDL level of 188 (10.4 mmol/L) is at the greatest risk for coronary artery disease. Obesity and high LDL cholesterol levels are significant risk factors for developing coronary artery disease. While factors like mitral valve prolapse (choice A) and a family history of CAD (choice B) can contribute to the risk, they are not as significant as obesity and high LDL levels. Choice C, a 56-year-old male with high HDL and taking atorvastatin, is actually at lower risk due to the high HDL levels and being on statin therapy, which helps reduce cholesterol levels and lower the risk of coronary artery disease.
Which of the following is a common cause of chronic liver disease?
- A. Alcohol abuse.
- B. Hepatitis C infection.
- C. Obesity.
- D. Smoking.
Correct Answer: B
Rationale: Hepatitis C infection is a common cause of chronic liver disease due to its long-term effects on the liver. Hepatitis C can lead to liver inflammation, fibrosis, cirrhosis, and even liver cancer. Alcohol abuse can also cause liver damage, but hepatitis C infection is specifically known for its chronic impact on liver health. Obesity and smoking, while detrimental to overall health, are not typically direct causes of chronic liver disease like hepatitis C infection.
A middle-aged adult with a family history of CAD has the following: total cholesterol 198 (11 mmol/L); LDL cholesterol 120 (6.7 mmol/L); HDL cholesterol 58 (3.2 mmol/L); triglycerides 148 (8.2 mmol/L); blood sugar 102 (5.7 mmol/L); and C-reactive protein (CRP) 4.2. The health care provider prescribes a statin medication and aspirin. The client asks the nurse why these medications are needed. Which is the best response by the nurse?
- A. The labs indicate severe hyperlipidemia and the medications will lower your LDL, along with a low-fat diet.
- B. The triglycerides are elevated and will not return to normal without these medications.
- C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications prescribed.
- D. These medications will reduce the risk of type 2 diabetes.
Correct Answer: C
Rationale: CRP is a marker of inflammation, which is elevated in cardiovascular disease. Statins and aspirin help lower CRP and reduce the risk of heart attacks and strokes.
The healthcare provider is assessing a client who is receiving hemodialysis for the first time. Which of the following findings should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Nausea and vomiting.
- C. Fatigue.
- D. Headache.
Correct Answer: B
Rationale: Nausea and vomiting are critical symptoms that should be reported immediately when a client is receiving hemodialysis for the first time. These symptoms could indicate a severe complication, such as hypotension, infection, electrolyte imbalance, or other adverse reactions to the procedure. It is essential to address these symptoms promptly to prevent further complications or harm to the client. Choices A, C, and D are not immediate concerns during the first hemodialysis session and can be addressed appropriately after addressing the urgent issue of nausea and vomiting.
A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the:
- A. Back of the mouth.
- B. Nose.
- C. Sinus channel below the right eye.
- D. Upper gingival mucosa in the space between the upper gums and lip.
Correct Answer: D
Rationale: The correct answer is D: Upper gingival mucosa in the space between the upper gums and lip. A transsphenoidal hypophysectomy involves accessing the pituitary gland through an incision in the upper gingival mucosa, providing direct access to the pituitary gland without external scars. Choices A, B, and C are incorrect because the surgery is not performed through the back of the mouth, the nose, or the sinus channel below the right eye. It is crucial for the client to understand the specific location of the incision to ensure accurate preoperative education and expectations.