Nokea
Which of the following will the nurse observe in the ictal phase of a generalized tonic-clonic seizure?
- A. Linking in one extremity that spreads gradually to adjacent areas.
- B. Vacant staring and abruptly ceasing all activity.
- C. Facial grimaces, patting motions, and lip smacking.
- D. Loss of consciousness, body stiffening, and violent muscle contractions.
Correct Answer: D
Rationale: The ictal phase of a generalized tonic-clonic seizure is characterized by loss of consciousness, body stiffening (tonic phase), and violent muscle contractions (clonic phase). The other options describe focal or absence seizures.
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A 28-year-old client with cancer is afraid of experiencing a febrile reaction associated with blood transfusions. He asks the nurse if this will happen to him. The nurse's best response is which of the following?
- A. Febrile reactions are caused when antibodies on the surface of blood cells in the transfusion are directed against antigens of the recipient.
- B. Febrile reactions can usually be prevented by administering antipyretics and antihistamines before the start of the transfusion.
- C. Febrile reactions are rarely immune-mediated and can be a sign of hemolytic transfusion.
- D. Febrile reactions primarily occur within 15 minutes after initiation of the transfusion and can occur during the blood transfusion.
Correct Answer: B
Rationale: Febrile reactions can often be prevented with premedication like antipyretics and antihistamines, which is a reassuring and accurate response for the client.
A 58-year-old female with a family history of CAD is being seen for the annual physical examination. Fasting lab test results include: Total cholesterol 198; LDL cholesterol 120; HDL cholesterol 58; Triglycerides 148; Blood sugar 102; and C-reactive protein (CRP) 4.2. The health care provider informs the client that she will be started on a statin medication and aspirin. The client asks the nurse why she needs to take these medications. 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 be lowered to normal with these medications.'
- C. The CRP is elevated indicating inflammation seen in cardiovascular disease, which can be lowered by the medications ordered.'
- D. The medications are not indicated since your lab values are all normal.'
Correct Answer: C
Rationale: Elevated CRP (4.2) indicates inflammation associated with cardiovascular risk. Statins and aspirin reduce inflammation and prevent cardiovascular events, addressing the client's risk profile.
A client with colon cancer undergoes surgical removal of a segment of colon and creation of a sigmoid colostomy. What assessments by the nurse indicate the client is developing complications within the first 24 hours? Select all that apply.
- A. Coarse breath sounds auscultated bilaterally at the bases.
- B. Dusky appearance of the stoma.
- C. No drainage in the ostomy appliance.
- D. Temperature greater than 101.2°F (38.5°C).
- E. Decreased bowel sounds.
Correct Answer: B,C,D
Rationale: A dusky stoma (B) indicates poor blood supply, no drainage (C) suggests obstruction or dysfunction, and fever (D) may indicate infection, all of which are complications post-colostomy. Coarse breath sounds (A) and decreased bowel sounds (E) are not necessarily indicative of immediate complications.
College freshman are participating in a study abroad program. When teaching them about hepatitis B, the nurse should instruct the students on:
- A. Water sanitation.
- B. Single dormitory rooms.
- C. Vaccine for hepatitis B.
- D. Safe sexual practices.
Correct Answer: D
Rationale: Hepatitis B is transmitted via blood and body fluids, so safe sexual practices (D) are critical for prevention. Water sanitation (A) is more relevant for hepatitis A. Single rooms (B) are unnecessary. The vaccine (C) is preventive but not the focus of behavioral instruction.
A client has a Jackson-Pratt drainage tube in place the first day after surgical repair of a ruptured diverticulum. The client asks the nurse the purpose of the drain. What is the nurse's best response?
- A. œThe drainage tube is used to prevent infection in the peritoneal cavity.'
- B. œThe drainage tube is used to prevent bleeding into the peritoneal cavity.'
- C. œThe drainage tube is used to prevent pressure on on the bladder.'
- D. œThe drainage tube is used to prevent pressure on the gallbladder.'
Correct Answer: A
Rationale: A Jackson-Pratt drain removes fluid and blood from the surgical site, preventing infection in the peritoneal cavity by reducing fluid accumulation post-diverticulum repair.