Nokea
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
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Which intervention should the nurse implement when caring for the client diagnosed with encephalitis? Select all that apply.
- A. Turn the client every two (2) hours.
- B. Encourage the client to increase fluids.
- C. Keep the client in the supine position.
- D. Assess for deep vein thrombosis (DVT).
- E. Assess for any alterations in elimination.
Correct Answer: A,D,E
Rationale: Turning every 2 hours (A) prevents pressure ulcers, assessing DVT (D) addresses immobility risks, and monitoring elimination (E) ensures bowel/bladder function. Increased fluids (B) depend on status, and supine positioning (C) may increase ICP.
Which client statement indicates understanding of myasthenia gravis management?
- A. I'll take my medication whenever I feel weak.'
- B. I'll avoid crowds to prevent infections.'
- C. I'll exercise vigorously every morning.'
- D. I'll skip doses if I feel better.'
Correct Answer: B
Rationale: Avoiding crowds reduces infection risk, which is critical in myasthenia gravis due to immunosuppressive therapy.
Which diagnostic test is used to confirm the diagnosis of Amyotrophic Lateral Sclerosis (ALS)?
- A. Electromyogram (EMG).
- B. Muscle biopsy.
- C. Serum creatine kinase (CK).
- D. Pulmonary function test.
Correct Answer: A
Rationale: EMG (A) detects abnormal muscle electrical activity characteristic of ALS, confirming the diagnosis. Muscle biopsy (B) is less specific, CK (C) may be elevated but isn’t diagnostic, and pulmonary tests (D) assess complications, not diagnosis.
Before the client undergoes the craniotomy, the nurse inserts a urinary catheter. How far should the catheter be inserted if the client is a male?
- A. 2'' to 4'' (5 to 10 cm)
- B. 4'' to 6'' (10 to 15 cm)
- C. 6'' to 8'' (15 to 20 cm)
- D. 8'' to 10'' (20 to 25.5 cm)
Correct Answer: D
Rationale: For a male, the urinary catheter should be inserted 8'' to 10'' to reach the bladder adequately.
Which priority goal would the nurse identify for a client diagnosed with Parkinson’s Disease (PD)?
- A. The client will be able to maintain mobility and swallow without aspiration.
- B. The client will verbalize feelings about the diagnosis of Parkinson’s Disease.
- C. The client will understand the purpose of medications administered for PD.
- D. The client will have a home health agency for monitoring at home.
Correct Answer: A
Rationale: Maintaining mobility and safe swallowing (A) are priority goals in Parkinson’s to prevent falls and aspiration. Verbalizing feelings (B), understanding medications (C), and home health (D) are secondary.