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: Gastrointestinal reflux disease is not typically a contraindication for sumatriptan.
Choice B rationale: Mild emphysema is not typically a contraindication for sumatriptan.
Choice C rationale: Hyperthyroidism is not typically a contraindication for sumatriptan.
Choice D rationale: Sumatriptan, a medication used for migraines, may elevate blood pressure, so it would be questionable for a client with hypertension.
Correct Answer is A
Explanation
Choice A rationale: In ALS, impaired physical mobility due to decreased motor agility and the inability to ambulate is a direct consequence of the disease.
Choice B rationale: Hopelessness might be a possible emotional response but doesn't address the client's physical limitations due to ALS.
Choice C rationale: Caregiver role strain is related to the family's ability to manage caregiving responsibilities and is not the primary concern for the client's physical mobility.
Choice D rationale: Impaired memory is not the primary issue in ALS; the client's inability to ambulate due to decreased motor function is the main focus for this nursing diagnosis.
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