Nursing Elites

1. What is the most appropriate action for a healthcare provider to take when a patient is experiencing a seizure?

• A. Protect the patient's head
• B. Restrain the patient's movements
• C. Insert an airway
• D. Give the patient water

Correct answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

2. How should a healthcare professional assess a patient with dehydration?

• A. Monitor skin turgor and check urine output
• B. Assess for jugular venous distention
• C. Auscultate lung sounds and monitor for fever
• D. Monitor for cyanosis and increased respiratory rate

Correct answer: A

Rationale: Correct Answer: When assessing a patient for dehydration, healthcare professionals should monitor skin turgor, as it indicates the degree of dehydration, and check urine output, as decreased urine output can be a sign of dehydration. Choices B, C, and D are incorrect because they do not directly assess for dehydration. Assessing for jugular venous distention (B) is more relevant for heart failure, auscultating lung sounds and monitoring for fever (C) are more relevant for respiratory infections, and monitoring for cyanosis and increased respiratory rate (D) are more indicative of respiratory distress rather than dehydration.

3. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

4. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

5. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?

• A. My son took my wallet to keep track of my spending
• B. My son always cooks my meals for me
• C. My son doesn't want me to drive alone
• D. I exercise every day with my son

Correct answer: A

Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.

Similar Questions