Exhibits

A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

Administer supplemental oxygen to the client.

Restrain the client.

Time the duration of the seizure.

Place a tongue depressor in the client's mouth.

Turn the client to the side

Answer and Explanation

Correct Answer : A,C,E

A.   The client is experiencing apnea and has decreased oxygen saturation, indicating a need for supplemental oxygen.
B.   Restraining a client during a seizure is dangerous and can cause injury.
C.   This information is crucial for determining the type of seizure and guiding treatment.
D.   Placing a tongue depressor in the client's mouth can cause trauma to the teeth and mouth and should never be done.
E.   Turning the client to the side helps prevent aspiration of saliva or vomit, protecting the airway.

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Correct Answer is A

Explanation

A. Elevating the head of the bed is a cornerstone of managing increased intracranial pressure (ICP). Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, helping to reduce ICP.
B. A brightly lit environment can stimulate the patient and increase ICP. A calm, dark environment is preferred.
C. Fluid restriction, not encouragement, is often necessary to manage ICP. Excessive fluid can increase intracranial volume.
D. Controlled coughing and deep breathing are important for lung expansion but coughing and straining can increase ICP. Gentle breathing exercises are preferred.

A. Widening pulse pressure B. Pulse oximetry 96% C. Increased deep tendon reflexes D. Increased heart rate

Correct Answer is D

Explanation

A. Widening pulse pressure is typically associated with increased cardiac output, which is opposite to what happens in hypovolemic shock.
B. Pulse oximetry 96% is a normal oxygen saturation level and does not indicate shock.
C. Increased deep tendon reflexes is not a typical finding in hypovolemic shock.
D. Increased heart rate is a classic compensatory mechanism in response to decreased blood volume. The body tries to maintain blood pressure by increasing heart rate.

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Exhibits A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the findings as an indication of hypovolemic shock?

Correct Answer is D

Explanation

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care?

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

Exhibits A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching? Client Statements

The emergency department nurse is preparing an infusion of IV alteplase for a client who suffered a cerebrovascular accident (CVA). Which of the following statements is accurate about the administration of alteplase?

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

Exhibits

A nurse is caring for a client who has a seizure disorder. (Select all that apply.)