A male client with a brain tumor is scheduled for a biopsy in the morning. During the admission procedure, the client has a tonic-clonic seizure that lasts 50 seconds. Following the seizure, the client is lethargic and confused and his wife tells the nurse that her husband has never had a seizure before and has always been alert and communicative. Which action should the nurse take?

Notify the emergency response team of the client's seizure.

Keep orienting the client to time and place until he is less confused.

Explain the postictal state that usually follows seizures.

Ask the wife to wait outside the room until the nurse can talk with her.

Answer and Explanation

The Correct Answer is B

Choice A: Notifying the emergency response team of the client's seizure is not a necessary action for the nurse, as the seizure has already stopped and there is no immediate threat to the client's life. This is a distractor choice.

Choice B: Keeping orienting the client to time and place until he is less confused is an appropriate action for the nurse, as this can help restore the client's cognitive function and reduce his anxiety after a seizure. Therefore, this is the correct choice.

Choice C: Explaining the postictal state that usually follows seizures is not a priority action for the nurse, as this can be done later when the client is more alert and receptive. This is another distractor choice.

Choice D: Asking the wife to wait outside the room until the nurse can talk with her is not a considerate action for the nurse, as this can increase her stress and worry about her husband's condition. This is a contraindicated choice.

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Correct Answer is C

Explanation

Choice A: An adolescent with multiple contusions due to a fall that occurred 2 days ago is not a client that the charge nurse should assign to the RN, as this is a stable and low-acuity client who can be safely cared for by the PN. This is a distractor choice.

Choice B: A 75-year-old client with renal calculi who requires urine straining is not a client that the charge nurse should assign to the RN, as this is a routine and non-complex task that can be performed by the PN. This is another distractor choice.

Choice C: A 30-year-old depressed client who admits to suicide ideation is a client that the charge nurse should assign to the RN, as this is an unstable and high-risk client who requires close monitoring, assessment, and intervention by the RN. Therefore, this is the correct choice.

Choice D: A 64-year-old client who had a total hip replacement the previous day is not a client that the charge nurse should assign to the RN, as this is a postoperative and moderate-acuity client who can be managed by the PN under the supervision of the RN. This is another distractor choice.

A. Blood alcohol level of 0.09% (90 mmol/L) B. Six hours of sleep in the past three days. C. Serum lithium level of 1.6 mEq/L (1.6 mmol/L) D. Weight loss of 10 pounds (4.5 kg) in past month.

Correct Answer is C

Explanation

Choice A: Blood alcohol level of 0.09% (90 mmol/L) is not the most important finding for the nurse to report, as this is within the reference range and does not indicate alcohol intoxication or withdrawal, which can affect the client's mental status and mood stability. This is a distractor choice.

Choice B: Six hours of sleep in the past three days is not the most important finding for the nurse to report, as this is a common symptom of bipolar disorder during manic episodes and does not require immediate intervention by the health care provider. This is another distractor choice.

Choice C: Serum lithium level of 1.6 mEq/L (1.6 mmol/L) is the most important finding for the nurse to report, as this indicates lithium toxicity, which can cause neurological and renal impairment and potentially fatal complications such as seizures, coma, and cardiac dysrhythmias. Therefore, this is the correct choice.

Choice D: Weight loss of 10 pounds (4.5 kg) in past month is not the most important finding for the nurse to report, as this may be related to decreased appetite or increased activity during manic episodes and does not pose an immediate threat to the client's health or safety. This is another distractor choice.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

Days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects that the client had a pulmonary embolus. Which action should the nurse take first?

The nurse is caring for a group of clients with the help of a practical nurse (PN). Which nursing action(s) should the nurse assign to the PN? (Select all that apply.)

A 46-year-old male client who had a myocardial infarction (MI) 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Two days after surgical fixation of a fractured femur, a client suddenly reports chest pain and difficulty in breathing. The nurse suspects the client had a pulmonary embolus. Which action should the nurse take first?

The nurse is educating a client about essential hypertension prevention. Which information should the nurse provide? (Select all that apply.)

A mother brings her 4-month-old son to the clinic with a quarter taped over his umbilicus and tells the nurse the quarter is supposed to fix her child's hernia. Which explanation should the nurse provide?

An adult with arthritis has been receiving treatment with naproxen and now reports ongoing stomach pain, increasing weakness, and fatigue. Which laboratory test should the nurse monitor?