A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

Oral suction equipment

Tongue depressor

Tracheostomy tray

Wrist restraints

Answer and Explanation

The Correct Answer is A

A. Oral suction equipment is correct. During a seizure, there is a risk of aspiration due to the loss of airway control. Oral suction equipment should be readily available in the room to clear the airway if needed, especially if the client experiences a seizure with oral secretions.

B. Tongue depressor is incorrect. A tongue depressor should never be used during a seizure. Inserting a tongue depressor into the mouth can result in injury to both the client and the caregiver and should be avoided.

C. Tracheostomy tray is incorrect. While a tracheostomy tray might be necessary for clients with tracheostomies, it is not a standard requirement for clients on seizure precautions unless the client has specific respiratory concerns or requires a tracheostomy for airway management.

D. Wrist restraints is incorrect. Wrist restraints are not recommended during a seizure, as they can cause injury and impede movement. Instead, the goal is to provide a safe environment to prevent injury during a seizure.

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Correct Answer is C

Explanation

A. Decreased body temperature is incorrect. A thyroid storm is characterized by a hypermetabolic state, so a decreased body temperature would be inconsistent with the condition. In fact, patients with thyroid storm typically have increased body temperature (fever).

B. Increased incisional drainage is incorrect. While increased drainage could indicate a wound infection or other surgical complications, it is not a primary indicator of thyroid storm, which involves a hyperactive thyroid response.

C. Hypertension is correct. Thyroid storm is a severe, acute exacerbation of hyperthyroidism, and it is associated with hypertension, tachycardia, fever, and other symptoms of sympathetic nervous system overactivity.

D. Bradycardia is incorrect. Bradycardia would be expected in conditions like hypothyroidism, not thyroid storm. Thyroid storm typically presents with tachycardia, which is a hallmark sign.

A. The AP points the probe posteriorly. B. The AP pulls the pinna up and back. C. The AP positions the client facing her. D. The AP inserts the probe with a straight, forward motion.

Correct Answer is B

Explanation

A. The AP points the probe posteriorly is incorrect. When using a tympanic thermometer for adults or children older than 3 years, the probe should be directed posteriorly and slightly upwards to align with the ear canal. The posterior direction is correct for adults, but this phrasing is not precise enough for the intended technique.

B. The AP pulls the pinna up and back is correct. When taking the temperature of a client older than 3 years using a tympanic thermometer, the pinna (ear) should be pulled up and back to straighten the ear canal and ensure accurate measurement. This action indicates the AP understands proper technique.

C. The AP positions the client facing her is incorrect. The client’s position does not directly affect the ability to take a tympanic temperature. The focus should be on positioning the ear and probe, not on facing the nurse.

D. The AP inserts the probe with a straight, forward motion is incorrect. The correct motion is straight into the ear canal, not forward, and it is more precise when the probe is inserted gently without forcing it.

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A nurse is supervising an assistive personnel (AP) obtain supplies for a client who is on seizure precautions. Which of the following materials should the AP place in the client's room?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following findings should indicate to the nurse that the client is developing a thyroid storm?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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