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While caring for a client who, while sitting in a chair, starts to experience a seizure, what action should the nurse take?
- A. Lower the client to the floor and place a pad under the client's head.
- B. Hold the client's head still to prevent injury.
- C. Restrain the client to prevent movement.
- D. Place the client in a supine position.
Correct Answer: A
Rationale: During a seizure, the priority is to lower the client to the floor to prevent injury and ensure their safety. Placing a pad under the client's head helps protect the head from injury. Choice B, holding the client's head still, is incorrect as it can lead to harm; it's essential to allow movement during a seizure to prevent neck injury. Choice C, restraining the client, is dangerous and can cause harm by restricting movement. Choice D, placing the client in a supine position, is also not recommended during a seizure as it does not provide adequate protection for the client.
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A client is crying while reading from a religious book and asks to be left alone. Which of the following actions should the nurse take?
- A. Contact the hospital's spiritual services.
- B. Ask what is making the client cry.
- C. Ensure no visitors or staff enter the room for a short time period.
- D. Turn on the television for a distraction.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to ensure no visitors or staff enter the room for a short time period. Respecting the client's wish for privacy during emotional moments is crucial for providing patient-centered care. Contacting spiritual services or asking about the reason for crying may intrude on the client's privacy and emotional space. Turning on the television for a distraction is not appropriate as it does not address the client's emotional needs or request for privacy.
The nurse is providing education about the importance of proper foot care to a patient diagnosed with diabetes mellitus. Which primary goal is the nurse trying to achieve?
- A. Prevention of plantar warts
- B. Prevention of foot fungus
- C. Prevention of neuropathy
- D. Prevention of amputation
Correct Answer: D
Rationale: The correct answer is D: Prevention of amputation. Patients with diabetes are at a higher risk of foot complications, such as ulcers, infections, and ultimately, amputations. Proper foot care education aims to prevent these serious complications. Choices A, B, and C are incorrect because while they are also important aspects of foot care, the primary goal in diabetes management is to prevent severe outcomes like amputation.
A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system.
- B. Use alcohol-based hand sanitizer when leaving the client's room.
- C. Clean contaminated surfaces in the client's room with a phenol solution.
- D. Have family members wear a gown and gloves when visiting.
Correct Answer: D
Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.
A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Administer the medication with the needle at a 30-degree angle.
- D. Administer the medication with the needle at a 15-degree angle.
Correct Answer: B
Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.
The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?
- A. Dry mucous membranes
- B. Increased urine output
- C. Decreased heart rate
- D. Elevated blood pressure
Correct Answer: B
Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.