A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?

An infant who has respiratory syncytial virus

A child who has bacterial meningitis

An infant who has hypertrophic pyloric stenosis

A child who has Kawasaki disease

Answer and Explanation

The Correct Answer is B

A. An infant who has respiratory syncytial virus (RSV) primarily experiences respiratory symptoms such as wheezing, coughing, and difficulty breathing. RSV does not typically cause seizures.
B. A child who has bacterial meningitis is at high risk for seizures due to increased intracranial pressure, cerebral irritation, and inflammation. Seizure precautions, including padded side rails, oxygen, and suction at the bedside, should be initiated.
C. An infant who has hypertrophic pyloric stenosis experiences projectile vomiting and dehydration but is not at risk for seizures.
D. A child who has Kawasaki disease is at risk for coronary artery complications, but seizures are not a common complication of this condition.

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Correct Answer is D

Explanation

A. Iron supplementation does not have a significant interaction with spironolactone.
B. Magnesium is not contraindicated with spironolactone, though excessive intake should be monitored.
C. Calcium does not pose a major risk when taken with spironolactone.
D. Potassium should be avoided because spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia, a potentially life-threatening condition characterized by cardiac arrhythmias and muscle weakness.

A. "Did anything in particular make you feel this way?" B. "Would you tell me more about the changes you see in your body?" C. "Do you ever think about harming yourself?" D. "How long have you had these feelings of uselessness?"

Correct Answer is C

Explanation

A. "Did anything in particular make you feel this way?" Understanding the cause of the client’s feelings is important, but assessing for immediate safety takes priority.
B. "Would you tell me more about the changes you see in your body?" Exploring the client’s perception of aging is useful, but it does not address potential risk for self-harm.
C. "Do you ever think about harming yourself?" This is the priority assessment question because feelings of worthlessness can indicate depression, which increases the risk of suicide in older adults. Assessing for self-harm ensures immediate safety.
D. "How long have you had these feelings of uselessness?" Identifying the duration of these feelings is relevant, but it is secondary to determining whether the client is at risk for self-harm.

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A nurse is receiving change-of-shift report for four clients. For which of the following clients should the nurse initiate seizure precautions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over- the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?

Correct Answer is D

Explanation

A nurse in a provider's office is talking with an older adult client who tells the nurse that they fear they are "aging badly" and feel "so useless." Which of the following assessment questions is the nurse's priority?

Correct Answer is C

Explanation

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