a young boy is recently diagnosed with a seizure disorder which of the following statements by the boys mother indicates a need for further teaching b

NCLEX-PN

Next Generation Nclex Questions Overview 3.0 ATI Quizlet

1. A young boy is recently diagnosed with a seizure disorder. Which of the following statements by the boy's mother indicates a need for further teaching by the nurse?

A. "I should make sure he gets plenty of rest."?
B. "I should get him a medical alert bracelet."?
C. "I should lay him on his back during a seizure."?
D. "I should loosen his clothing during a seizure."?

Correct answer: C

Rationale: The correct answer is "I should lay him on his back during a seizure."? This statement indicates a need for further teaching because a client having a seizure should be turned to the side to prevent aspiration of secretions. Choices A, B, and D are correct. Getting plenty of rest helps in managing seizures, having a medical alert bracelet informs others about the condition in case of emergency, and loosening clothing during a seizure ensures better air circulation and prevents injury. These actions demonstrate adequate understanding of the teaching provided.

2. A client with a left arm fracture complains of severe diffuse pain that is unrelieved by pain medication. On further assessment, the nurse notes that the client experiences increased pain during passive motion compared with active motion of the left arm. Based on these assessment findings, which action should the nurse take first?

A. Contacting the health care provider
B. Checking if it is time for more pain medication
C. Encouraging the client to continue active range of motion exercises of the left arm
D. Repositioning the client for comfort

Correct answer: A

Rationale: The correct answer is to contact the health care provider. The client with early acute compartment syndrome typically complains of severe diffuse pain that is unrelieved by pain medication. Additionally, the affected client experiences greater pain during passive motion compared to active motion. In this situation, it is crucial to notify the health care provider immediately for further evaluation and intervention. Contacting the health care provider is essential to ensure timely diagnosis and appropriate management of the condition. Checking for more pain medication, encouraging active range of motion exercises, or repositioning the client may not address the underlying issue of acute compartment syndrome and could delay necessary interventions. Therefore, the priority action should be to involve the healthcare provider for prompt assessment and treatment.

3. The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:

A. help decrease stimuli from the cerebral cortex.
B. stimulate hormonal changes in the brain.
C. help the client's circadian rhythm.
D. alert the hypothalamus in the brain.

Correct answer: A

Rationale: The nurse's actions of providing an analgesic medication and darkening the room aim to decrease stimuli from the cerebral cortex. Reduction of environmental stimuli, especially light and noise, from the cerebral cortex, which is an area of arousal, facilitates sleep. By decreasing input to this area, the client is more likely to fall asleep and stay asleep. Choices B, C, and D are incorrect because the scenario does not involve stimulating hormonal changes, influencing the circadian rhythm, or alerting the hypothalamus.

4. What is the purpose of the hydraulic lift (Hoyer lift)?

A. To assist clients who have had orthopedic surgery.
B. To assist clients who are unable to stand and extremely obese clients.
C. To assist clients of all ages in a hospital setting.
D. To assist clients with special needs.

Correct answer: B

Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.

5. Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?

A. "You will not be allowed to see your family member after the postmortem care is performed."?
B. "I am not able to assist you, but we can call pastoral care if you need any comfort."?
C. "Unfortunately, we are not allowed to incorporate any cultural practices in my preparations."?
D. "I will be ensuring that your family member is properly identified before they are transported."?

Correct answer: D

Rationale: The correct statement when preparing to provide postmortem care to the client's family is to assure them that the family member will be properly identified before transportation. This is crucial in ensuring the correct individual is being handled respectfully. Choices A, B, and C are incorrect as they do not address the essential aspect of ensuring the proper identification of the deceased before transportation. It is important to allow the family to see their loved one after postmortem care and, if possible, incorporate any cultural practices. Providing comfort and support to the family during this difficult time is also essential in delivering holistic care.