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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale: The signs and symptoms of urinary catheter obstruction include hematuria with clots, bladder spasms, and a feeling of urinary urgency. The nurse should increase the rate of the continuous bladder irrigation to flush out the clots and relieve the obstruction. The nurse should also monitor the client's vital signs, fluid balance, and pain level. The other options are not consistent with the client's presentation.

Choice B rationale: Shock would cause hypotension, tachycardia, and decreased urine output.

Choice C rationale: Hyponatremia would cause confusion, weakness, and seizures.

Choice D rationale: Urinary tract infection would cause fever, chills, and foul-smelling urine.

A. Stomatitis and Diarrhea B. Dyspnea and Anuria C. Confusion and Vomiting D. Nocturia and Oliguria

Correct Answer is D

Explanation

Choice A rationale: These are symptoms of advance renal failure. Stomatitis and diarrhea are signs of uremia, which is the accumulation of waste products in the blood.

Choice B rationale: Dyspnea and anuria are signs of fluid overload and kidney shutdown and indicate advanced renal failure.

Choice C rationale: Confusion and vomiting are signs of acidosis and electrolyte disturbances and occur in advanced stages of renal failure.

Choice D rationale: One of the early symptoms of renal insufficiency is nocturia, which is the need to urinate frequently at night. This occurs because the kidneys are unable to concentrate urine during the day and produce more urine at night. Another early symptom is oliguria, which is the production of less than 400 mL of urine per day. This occurs because the kidneys are unable to excrete enough urine to maintain fluid balance.

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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?

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