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A school nurse is teaching a parent about absence seizures.
Which information should the nurse include?
- A. This type of seizure can be mistaken for daydreaming
- B. Absence seizures typically last only a few seconds.
- C. The child may not remember the seizure episode afterward.
- D. There are usually no warning signs before an absence seizure occurs.
- E. Lip smacking or eye fluttering may accompany the seizure.
Correct Answer: E
Rationale: The correct answer is E because lip smacking or eye fluttering are common manifestations of absence seizures, providing crucial information for recognition and diagnosis. Choice A is incorrect as it does not specifically relate to absence seizures. Choice B is incorrect because absence seizures typically last 10-20 seconds, not just a few seconds. Choice C is incorrect as individuals experiencing absence seizures usually do not have memory issues afterward. Choice D is incorrect because some individuals may have warning signs before an absence seizure.
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A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.
Which of the following actions should the nurse plan to take?
- A. Apply a cold compress to the site.
- B. Elevate the affected arm above heart level.
- C. Place a warm, moist compress on the site.
- D. Massage the area to reduce inflammation.
Correct Answer: B
Rationale: The correct answer is B: Elevate the affected arm above heart level. Elevating the affected arm helps reduce swelling and promote circulation, aiding in the healing process. By elevating the arm above heart level, the nurse can assist in reducing inflammation and preventing further complications. Applying a cold compress (choice A) can be helpful for acute injuries, but it may not be the most appropriate initial action. Placing a warm, moist compress (choice C) can potentially worsen swelling in this case. Massaging the area (choice D) could aggravate the injury and increase inflammation.
A nurse is teaching a client about family planning using the basal body temperature method.
Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.
- B. Measure your temperature in the afternoon for the most accurate reading.
- C. A rise in body temperature of at least 2°F indicates ovulation has occurred.
- D. Use a standard digital thermometer for the most precise results.
Correct Answer: A
Rationale: The correct answer is A: Take your temperature immediately after waking and before getting out of bed. This instruction is part of basal body temperature monitoring for ovulation tracking. Body temperature is lowest upon waking and increases after ovulation, so taking the temperature before getting out of bed provides the most accurate baseline measurement. Choice B is incorrect because afternoon temperatures can fluctuate due to various factors. Choice C is incorrect as a rise of at least 0.4°F, not 2°F, indicates ovulation. Choice D is incorrect because a basal body temperature thermometer is more appropriate for this purpose than a standard digital thermometer.
A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.
A nurse is caring for a client who is in active labor.
The nurse should notify the provider for which of the following findings?
- A. Baseline fetal heart rate 115/min
- B. Three uterine contractions within 10 minutes
- C. Prolonged decelerations
- D. Moderate variability in the fetal heart rate
Correct Answer: C
Rationale: The correct answer is C: Prolonged decelerations. This finding indicates potential fetal distress, requiring immediate provider notification to assess and intervene. Baseline fetal heart rate (A) within normal range is reassuring. Three uterine contractions (B) could be normal. Moderate variability (D) is a positive sign of fetal well-being. The focus should be on abnormal findings like prolonged decelerations (C) that may indicate compromised fetal oxygenation.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member.
Which of the following actions should the nurse take first?
- A. Encourage the family to assign specific tasks to individual family members.
- B. Determine the roles of individual family members.
- C. Assist the family to establish a daily routine
- D. Refer the family to a grief support group.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps identify the strengths and abilities of each family member, allowing for effective delegation of tasks and responsibilities. By understanding each member's role, the nurse can promote a balanced distribution of duties and enhance the family's ability to cope with the situation. Encouraging the family to assign specific tasks (A) may be premature without knowing each member's capabilities. Establishing a daily routine (C) can come after roles are determined to provide structure. Referring to a grief support group (D) may be necessary but not the first step.