A family brought their 3-week-old infant to the hospital by ambulance after having a seizure at home.

The baby received phenytoin in the ambulance and arrived at the hospital on 1 L/minute oxygen with a 22-gauge peripheral IV line in the left saphenous vein.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Review H and P, nurse’s notes, flow sheet, and orders.

Call for a chest x-ray.

Hypocalcemia.

Monitor respiratory rate.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Reviewing the history and physical (H&P), nurse’s notes, flow sheet, and orders is a standard part of nursing care for any patient. However, in the case of a 3-week-old infant who has had a seizure, this action alone would not directly address the condition the infant is most likely experiencing.

Choice B rationale
While calling for a chest x-ray could be part of the diagnostic process for certain conditions, it is not typically the first action taken in response to a seizure in an infant.

Choice C rationale
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.

Choice D rationale

Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure. However, it does not specify the condition the infant is most likely experiencing.

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Correct Answer is C

Explanation

Choice A rationale
Allowing the client to express their feelings is an important part of providing psychosocial support. However, it does not specifically address the client’s need for acceptance.
Choice B rationale

Wearing gloves during the client interview can actually reinforce feelings of stigma and rejection, as it may suggest that the nurse is afraid of touching the client or catching their condition.
Choice C rationale
Offering a handshake during introductions can be a powerful gesture of acceptance, especially for a client with a visible skin condition like psoriasis. It communicates that the nurse is not afraid of physical contact and accepts the client as they are.
Choice D rationale
Encouraging the client to join a support group can provide them with a sense of community and shared experience, but it does not specifically address the client’s need for acceptance in their individual interactions with healthcare providers.

A. Pay close attention to the client’s account of the event. B. Report the incident to the university’s security department. C. Prevent the client from showering until all evidence is collected. D. Ascertain the client’s personal reaction to the reported rape.

Correct Answer is C

Explanation

Choice A rationale
Paying close attention to the client’s account of the event is important, but it is not the most crucial intervention. The nurse should listen empathetically and nonjudgmentally to the client’s account, but this should not take precedence over ensuring the client’s physical well- being and preserving evidence.
Choice B rationale

Reporting the incident to the university’s security department is not the most crucial intervention. While it is important to report the incident to the appropriate authorities, the nurse’s primary responsibility is to the client. Ensuring the client’s physical well-being and preserving evidence should take precedence.
Choice C rationale
Preventing the client from showering until all evidence is collected is the most crucial intervention. Showering can destroy valuable physical evidence that can be used in the investigation and prosecution of the crime.
Choice D rationale
Ascertaining the client’s personal reaction to the reported rape is important, but it is not the most crucial intervention. The nurse should provide emotional support and refer the client to counseling services, but this should not take precedence over ensuring the client’s physical well-being and preserving evidence.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of caring for a client diagnosed with psoriasis, which action by the nurse would address the client’s psychosocial need for acceptance?

Correct Answer is C

Explanation

A nurse in the emergency department is collecting evidence for a rape kit from a woman who reports that she was raped while returning to her dormitory from the university library. Which intervention is most crucial for the nurse to implement?

Correct Answer is C

Explanation

Which laboratory test results should the nurse monitor in a patient who has end-stage renal disease (ESRD)?

A client with schizophrenia is admitted to the hospital reporting auditory hallucinations. Which query is most important for the nurse to include in the client’s assessment?

The nurse is educating a patient who was admitted with a blood glucose level of 580 mg/dL on how to prevent complications related to diabetes mellitus. Which statement, if made by the patient, would indicate that they have understood the teaching?

The parents of a 6-year-old child recently diagnosed with Duchenne muscular dystrophy express that their child wants to continue attending swimming classes. How should the nurse respond?

When providing nursing care for a client after a gastric endoscopy, which intervention should the nurse include in the post-procedure plan of care for commonly occurring problems?

A caregiver brings a client with end-stage Alzheimer’s disease to the clinic for an appointment with the healthcare provider. The caregiver confides in the nurse about experiencing sleepless nights and frequent bouts of crying. What action should the nurse take?