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While assisting a female client to the toilet, the client begins to have a seizure, and the nurse eases her to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention should the nurse implement first?
- A. Document details of the seizure activity.
- B. Observe for lacerations on the tongue.
- C. Observe for prolonged periods of apnea.
- D. Evaluate for evidence of incontinence.
Correct Answer: A
Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.
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What information should the nurse include in the teaching plan of a client diagnosed with GERD?
- A. Sleep without using pillows
- B. Opt for five small meals throughout the day instead of three full meals with no snacks
- C. Minimize symptoms by wearing loose, comfortable clothing
- D. Engage in low-impact exercises like walking or swimming
Correct Answer: C
Rationale: The correct answer is C: 'Minimize symptoms by wearing loose, comfortable clothing.' Wearing loose, comfortable clothing can help reduce pressure on the abdomen, which can alleviate GERD symptoms. Option A is incorrect as sleeping without using pillows is not a recommended practice for managing GERD. Option B is incorrect because it suggests adjusting food intake to five small meals throughout the day instead of three full meals with no snacks, which may not be suitable for everyone with GERD. Option D is incorrect as avoiding participation in any aerobic exercise program is not a standard recommendation for managing GERD; in fact, engaging in low-impact exercises like walking or swimming can be beneficial.
A client with hypertension is prescribed a low-sodium diet. Which food should the client avoid?
- A. Fresh fruits
- B. Processed cheese
- C. Whole grain bread
- D. Fresh vegetables
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?
- A. Limited eye movement.
- B. Decreased peripheral vision.
- C. Blurred distance vision.
- D. Photosensitivity.
Correct Answer: B
Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.
An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?
- A. Capillary refill takes > 3 seconds.
- B. Episodes of vertigo and loss of balance.
- C. Average daily output of 1200 ml.
- D. Pulse rate of 110 beats/minute and dyspnea upon exertion.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client who is receiving general anesthesia begins to demonstrate symptoms of malignant hyperthermia. Which intervention should the perioperative nurse prepare to implement first?
- A. Ensure patency of an indwelling catheter and measure hourly intake and output.
- B. Prepare for cessation of the anesthesia and the surgical procedure.
- C. Obtain specimens of ABGs and serum electrolytes.
- D. Initiate cooling measures using iced normal saline by nasogastric lavage.
Correct Answer: B
Rationale: The correct answer is B: Prepare for cessation of the anesthesia and the surgical procedure. Malignant hyperthermia is a severe reaction to certain medications used during general anesthesia. The immediate intervention to manage malignant hyperthermia is to stop the triggering agents, which include anesthesia and surgery. Ensuring patency of an indwelling catheter and measuring intake and output, obtaining specimens of ABGs and serum electrolytes, and initiating cooling measures are important interventions but should follow the immediate action of stopping the anesthesia and surgery to address the life-threatening condition of malignant hyperthermia.