A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Presence of absence seizures

Postictal phase

Presence of automatisms

Aura phase

Answer and Explanation

The Correct Answer is B

The nurse should use the term "postictal phase" when documenting the client's difficulty arousing and sleepiness for several hours following a generalized tonic-clonic seizure. The postictal phase is the period of time immediately following a seizure during which the client may be difficult to arouse and very sleepy.

Presence of absence seizures, presence of automatisms, and aura phase are not appropriate descriptions for the nurse to use when documenting this finding in the medical record. Absence seizures are a type of seizure characterized by brief episodes of staring and unresponsiveness. Automatisms are repetitive, unconscious movements that can occur during a seizure. The aura phase is a warning sign that can occur before a seizure.

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Correct Answer is D

Explanation

Having the client lie prone several times each day is an appropriate nursing intervention for a client who is 2 days postoperative following an above-the-knee amputation. Lying prone can help prevent hip ﬂexion contractures, which can occur after an above-the-knee amputation².

a. Elevating the foot of the bed is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

b. Encouraging sitting up as much as possible is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

c. Elevating the stump on a pillow is not an appropriate intervention for a client who is 2 days postoperative following an above-the-knee amputation.

A. "Skeletal traction is better than skin traction for reducing a fracture." B. "Clients in skin traction have more mobility than those in skeletal traction." C. "Skeletal traction has less risk for infection than skin traction." D. "Clients in skin traction have more discomfort than those in skeletal traction."

Correct Answer is A

Explanation

a.Skeletal traction is often better than skin traction for reducing and maintaining alignment of a fracture because it involves the insertion of pins, wires, or screws directly into the bone, allowing for greater force and stability.

b.Clients in skin traction typically have less mobility compared to those in skeletal traction. Skin traction is usually used for short-term purposes or less severe fractures and involves attaching weights to the skin using adhesive materials or bandages, which can limit movement to some extent.

c.Skeletal traction involves inserting hardware into the bone, which creates an entry point for potential infection. Therefore, it has a higher risk for infection compared to skin traction, which does not involve invasive procedures.

d.While both types of traction can cause discomfort, skeletal traction is typically more invasive and can be associated with more discomfort and pain due to the pins or wires inserted into the bone. Skin traction, while uncomfortable due to the adhesive and pressure on the skin, generally causes less discomfort than skeletal traction.

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A nurse is caring for a client who is difficult to arouse and very sleepy for several hours following a generalized tonic-clonic seizure. Which of the following descriptions should the nurse use when documenting this finding in the medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 days postoperative following an above-the-knee amputation. Which of the following is an appropriate nursing intervention for the client at this time?

Correct Answer is D

Explanation

A nurse is discussing skeletal and skin traction with a newly licensed nurse. Which of the following statements should the nurse identify as an indication that the newly licensed nurse understands these therapies?

Correct Answer is A

Explanation

A nurse is assisting in the planning of preventative care for a client who is restless following a traumatic brain injury with increased intracranial pressure. Which of the following is an appropriate nursing action?

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A nurse is collecting data from a client who has a score of 8 using the Glasgow Coma Scale. Which of the following findings should the nurse expect?

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?

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A nurse is contributing to the plan of care for a client who is postoperative following a total hip arthroplasty. Which of the following information should the nurse include?

A nurse is caring for a client who has a spinal cord injury. The nurse suspects that the client has autonomic dysreﬂexia. Which of the following actions should the nurse take first?