Nursing Elites

1. 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 on the tongue.
• C. Observe for prolonged periods of apnea.
• D. Evaluate for evidence of incontinence.

Correct answer: A

Rationale: Documenting details of the seizure activity is the priority intervention as it is crucial for medical records and future care planning. This documentation can provide vital information for healthcare providers in understanding the type, duration, and characteristics of the seizure. Observing for lacerations on the tongue, prolonged periods of apnea, or evidence of incontinence are important assessments, but they come after documenting the seizure activity.

2. Which signs/symptoms would be considered classical signs of meningeal irritation?

• A. Positive Kernig sign, diarrhea, and headache
• B. Negative Brudzinski sign, positive Kernig sign, and irritability
• C. Positive Brudzinski sign, positive Kernig sign, and photophobia
• D. Negative Kernig sign, vomiting, and fever

Correct answer: C

Rationale: The correct answer is C: Positive Brudzinski sign, positive Kernig sign, and photophobia are considered classical signs of meningeal irritation. The Kernig sign is positive when the leg is extended at the knee and then raised, resulting in pain and resistance. The Brudzinski sign is positive when flexing the neck causes flexion of the hips and knees due to meningeal irritation. Photophobia, or sensitivity to light, is a common symptom due to meningeal inflammation. Choices A, B, and D are incorrect because they do not include the classic signs associated with meningeal irritation.

3. A client with rheumatoid arthritis is prescribed methotrexate. Which instruction should the nurse include in the teaching plan?

• A. Avoid taking folic acid supplements
• B. Report any signs of infection immediately
• C. Limit fluid intake to prevent edema
• D. Increase intake of high-calcium foods

Correct answer: B

Rationale: The correct instruction that the nurse should include in the teaching plan for a client prescribed methotrexate is to report any signs of infection immediately. Methotrexate can suppress the immune system, making the individual more susceptible to infections. Reporting signs of infection promptly allows for timely intervention. Choices A, C, and D are incorrect. Avoiding folic acid supplements is not recommended because methotrexate can lead to folate deficiency, so supplementation may be necessary. There is no direct correlation between fluid intake limitation and methotrexate use. Increasing high-calcium foods is not specifically related to methotrexate therapy for rheumatoid arthritis.

4. The nurse is caring for a client with a nasogastric tube. Which action should the nurse take to ensure proper functioning of the tube?

• A. Flush the tube with 50 mL of normal saline every 8 hours
• B. Clamp the tube when not in use
• C. Position the client in a supine position
• D. Verify tube placement by checking pH of gastric contents

Correct answer: D

Rationale: Verifying tube placement by checking the pH of gastric contents is crucial to ensure the nasogastric tube is correctly positioned in the stomach. This action helps prevent complications such as aspiration. Flushing the tube with normal saline every 8 hours is not necessary for ensuring proper functioning of the tube. Clamping the tube when not in use may lead to the build-up of gastric secretions and blockages. Positioning the client in a supine position is not directly related to ensuring the proper functioning of the nasogastric tube.

5. After hospitalization for SIADH, a client develops pontine myelinolysis. Which intervention should the nurse implement first?

• A. Reorient the client to the room
• B. Place an eye patch on one eye
• C. Evaluate the client's ability to swallow
• D. Perform range of motion exercises

Correct answer: C

Rationale: Evaluating the client's ability to swallow is the priority intervention in this scenario. Pontine myelinolysis can affect neurological functions, including swallowing ability, putting the client at risk for aspiration. Assessing the client's ability to swallow will help prevent complications such as aspiration pneumonia. Reorienting the client to the room, placing an eye patch, or performing range of motion exercises are not as critical as ensuring the client can safely swallow.

Similar Questions