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 C

Explanation

A. A slight increase in temperature is common after surgery and might not necessarily indicate shock.
B. A slight decrease in respiratory rate is not indicative of shock. In fact, as shock progresses, respiratory rate often increases.
C. An increased heart rate is a classic compensatory mechanism in response to decreased blood volume, as the body tries to maintain blood pressure.
D. While a decrease in urinary output can be a sign of impending shock, it's often a later sign. In the early stages, the body prioritizes blood flow to vital organs, and urine output may still be within normal limits.

A. Jerking contractions of the head and neck B. Pinpoint pupils C. Pronation of the arms D. Dorsiflexion of the great toe

Correct Answer is D

Explanation

A. Jerking contractions of the head and neck is more indicative of seizures or other neurological conditions.
B. Pinpoint pupils can be associated with various conditions, including opioid overdose or pontine hemorrhage, but it's not specifically related to Babinski's sign.
C. Pronation of the arms is a general assessment finding, not specifically indicative of a neurological issue.
D. Dorsiflexion of the great toe is the classic response for Babinski's sign. It is an abnormal reflex indicating upper motor neuron damage.

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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 returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is C

Explanation

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Correct Answer is D

Explanation

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

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A nurse is caring for a client who is experiencing anaphylactic shock in response to the administration of penicillin. Which of the following medications should the nurse administer first?

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?

A nurse is caring for a client who has had a stroke. Exhibits Select the 3 findings that require immediate follow-up.

A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

Exhibits

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