The nurse observes a novice nurse caring for a client experiencing status epilepticus. It will require immediate intervention if the novice nurse does which of the following?
Activates the rapid response team (RRT).
Loosens any restrictive clothing.
Places the client in a lateral position.
Prepares to administer intravenous valproate acid.
The Correct Answer is D
Choice A rationale: Activates the rapid response team (RRT) - Status epilepticus is a medical emergency requiring immediate intervention. Activating the rapid response team would ensure a prompt response to the situation.
Choice B rationale: Loosens any restrictive clothing - It is important for patient safety and comfort.
Choice C rationale: Places the client in a lateral position - This is a recommended positioning to prevent aspiration during a seizure.
Choice D rationale: Prepares to administer intravenous valproate acid - Valproic acid is not the first drug during epilepsy hence this action would necessitate immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: Hormone therapy (HT) is used to treat menopausal symptoms, not PID.
Choice B rationale: Irregularities in the menstrual cycle is not a common complications of PID.
Choice C rationale: Changes in secondary sex characteristics is not a common complications of PID.
Choice D rationale: Pelvic inflammatory disease (PID) is an infection of the female reproductive organs that can cause scarring and damage to the fallopian tubes, ovaries, and uterus. This can lead to ectopic pregnancy, chronic pelvic pain, and infertility.
Correct Answer is B
Explanation
Choice A rationale: Rotating the neck to one side while observing the eyes moving to the opposite side is a procedure for testing for oculocephalic reflex or doll's eye
phenomenon, which indicates brainstem function.
Choice B rationale: This is the correct answer. Kernig's sign is a clinical sign that indicates meningitis, which is an inflammation of the membranes that cover the brain and spinal cord. To test for Kernig's sign, the nurse should flex the patient's hip to 90 degrees and then attempt to extend the knee. A positive Kernig's sign is when the patient
experiences pain in the lower back or hamstring, resists knee extension, or involuntarily flexes the opposite leg.
Choice C rationale: Stroking the lateral aspect of the sole of the patient's foot and observing for dorsiflexion of the big toe is a procedure for testing for Babinski's sign, which indicates upper motor neuron lesion or damage.
Choice D rationale: Passively flexing the patient's neck forward and observing for hip and knee flexion is a procedure for testing for Brudzinski's sign, which also indicates meningitis.
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