Nursing Elites

1. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

• A. Administer antiseizure medications promptly.
• B. Use oral airway devices during seizures.
• C. Pad the side rails of the bed.
• D. Apply restraints during the seizure to prevent injury.

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

2. A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?

• A. I steal things because it’s the only way I can keep my mind off my bad marriage
• B. I can’t believe I was accused of something I didn’t do
• C. I don’t want to talk about my feelings right now; we will talk more next time
• D. I think that people should earn money honestly, even though I stole

Correct answer: D

Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.

3. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?

• A. Baby oil
• B. Antibiotic ointment
• C. Petroleum jelly
• D. Alcohol wipes

Correct answer: C

Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.

4. A client is in active labor and is receiving an epidural for pain relief. Which of the following should the nurse monitor as the priority?

• A. Fetal heart rate
• B. Client's blood pressure
• C. Client's respiratory rate
• D. Client's pain level

Correct answer: B

Rationale: The most common side effect of an epidural is hypotension, which can compromise placental perfusion. Monitoring the client's blood pressure is the priority to ensure maternal and fetal well-being. Fetal heart rate is important but monitoring the client's blood pressure takes precedence due to the risk of hypotension. Respiratory rate and pain level monitoring are also important but not the priority in this scenario.

5. A nurse at a provider’s office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective?

• A. “I don’t have muscle spasms as frequently.”
• B. “I haven’t gotten any colds, even though it is flu season.”
• C. “I feel like my nerve pain has improved.”
• D. “It is easier to urinate now.”

Correct answer: A

Rationale: The correct answer is A: "I don’t have muscle spasms as frequently." The nurse should identify that dantrolene relaxes skeletal muscles, so a decrease in muscle spasms indicates the medication is effective. Choice B is incorrect as cold prevention is not related to dantrolene. Choice C is incorrect because nerve pain improvement is not a direct effect of dantrolene. Choice D is incorrect as dantrolene's action does not affect urination.

Similar Questions