Nokea
Which client behavior during a seizure requires immediate intervention?
- A. Lip smacking
- B. Rhythmic limb jerking
- C. Incontinence
- D. Tongue biting
Correct Answer: D
Rationale: Tongue biting during a seizure can cause airway obstruction or severe injury, requiring immediate intervention to protect the airway.
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The client is diagnosed with arboviral encephalitis. Which priority intervention should the nurse implement?
- A. Place the client in strict isolation.
- B. Administer IV antibiotics.
- C. Keep the client in the supine position.
- D. Institute seizure precautions.
Correct Answer: D
Rationale: Arboviral encephalitis increases seizure risk due to brain inflammation. Seizure precautions (D) are the priority. Isolation (A) is unnecessary, antibiotics (B) are ineffective for viral causes, and supine position (C) may increase ICP.
While awaiting the diagnostic test results for a client with possible meningitis, which transmission-based precautions are the supplement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: A
Rationale: Meningitis, especially bacterial, is often transmitted via respiratory droplets, necessitating droplet precautions.
The client has had recurrent episodes of low back pain. Which statement indicates that the client has incorporated positive lifestyle changes to decrease the incidence of future back problems?
- A. “I stoop and avoid bending and twisting when lifting objects.”
- B. “I can walk farther if I wear my old comfortable shoes.”
- C. “I can walk only on weekends but walk 5 miles each day.”
- D. “I sit for 2 to 3 hours with my legs elevated for pain control.”
Correct Answer: A
Rationale: Stooping and avoiding bending and twisting motions when lifting objects lessen the likelihood of injury. The client should wear supportive shoes. The client should include regular daily exercise as a program (not excessive walking over 2 days on the weekend). Clients should avoid prolonged sitting or standing.
The nurse is caring for clients on a medical-surgical floor. Which clients should be assessed first?
- A. The 65-year-old client diagnosed with seizures who is complaining of a headache that is a '2' on a 1-to-10 scale.
- B. The 24-year-old client diagnosed with a T10 spinal cord injury who cannot move his toes.
- C. The 58-year-old client diagnosed with Parkinson’s disease who is crying and worried about her facial appearance.
- D. The 62-year-old client diagnosed with a cerebrovascular accident who has a resolving left hemiparesis.
Correct Answer: B
Rationale: Inability to move toes in a T10 SCI (B) may indicate neurological deterioration or edema, requiring immediate assessment. Mild headache (A), emotional distress (C), and resolving hemiparesis (D) are less urgent.
The nurse is caring for a client diagnosed with encephalitis. Which is an expected outcome for the client?
- A. The client will regain as much neurological function as possible.
- B. The client will have no short-term memory loss.
- C. The client will have improved renal function.
- D. The client will apply hydrocortisone cream daily.
Correct Answer: A
Rationale: The goal for encephalitis is to maximize neurological recovery (A), as inflammation may cause deficits. No memory loss (B) is unrealistic, renal function (C) is unrelated, and hydrocortisone cream (D) is not indicated.