Nokea
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 to the tongue
- C. Observe for prolonged periods of apnea
- D. Evaluate for evidence of incontinence
Correct Answer: C
Rationale: Observing for prolonged periods of apnea is critical to ensure the client's airway remains patent and to prevent hypoxia.
You may also like to solve these questions
A 9-month-old infant has a grade III/VI, harsh, rumbling, continuous murmur in the left infraclavicular fossa and pulmonic area. A chest radiograph reveals cardiac enlargement. The primary care pediatric nurse practitioner will refer the infant to a pediatric cardiologist and prepare the parents for which intervention to repair this defect?
- A. Cardiopulmonary bypass surgery
- B. Coil insertion in the catheterization laboratory
- C. Indomethacin administration
- D. Observation for spontaneous closure
Correct Answer: B
Rationale: This murmur is characteristic of a PDA and, because of cardiac enlargement, represents a larger shunt, requiring repair. Infants older than 8 months may have a coil or plug inserted into the shunt in the cardiac catheterization laboratory.
Common presenting features of myotonic dystrophy are:
- A. Floppy infant
- B. Corneal opacities
- C. Frontal baldness
- D. Macro-orchidism
Correct Answer: D
Rationale: Macro-orchidism: Myotonic dystrophy is characterized by muscle weakness and myotonia. Macro-orchidism (enlarged testes) is a distinctive feature, especially in male patients.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client’s health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
- A. Schedule an electrocardiogram just before the MRI.
- B. Notify the healthcare provider before scheduling the MRI.
- C. Call the physician and request a laboratory draw for cardiac enzymes.
- D. Instruct the client to increase fluid intake the day before the MRI.
Correct Answer: B
Rationale: Clients with pacemakers are generally not candidates for MRI due to the risk of device malfunction or tissue damage. The healthcare provider must be notified to determine the best course of action.
The MOST common cause of sudden death in competitive athletes is
- A. aortic stenosis
- B. hypertrophic cardiomyopathy
- C. coronary artery abnormalities
- D. myocarditis
Correct Answer: B
Rationale: Hypertrophic cardiomyopathy is the leading cause of sudden death in competitive athletes.
Shone complex consist of the following EXCEPT
- A. coarctation of the aorta
- B. subvalvar aortic stenosis
- C. valvar aortic stenosis
- D. pulmonic stenosis
Correct Answer: D
Rationale: Pulmonic stenosis is not part of Shone complex.