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 C
Explanation
Choice A rationale: BSE will not reduce the risk of dying from breast cancer, but it may help you detect breast cancer earlier, when it is more treatable.
Choice B rationale: BSE should be done once a month, preferably at the same time each month. For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.
Choice C rationale: For women who have menstrual periods, the best time to do BSE is a few days after the period ends, when the breasts are less tender and swollen. For women who do not have menstrual periods, such as those who are pregnant, breastfeeding, or postmenopausal, they can choose a fixed date, such as the first day of each month, to do BSE.
Choice D rationale: Annual mammograms are recommended for women aged 40 and older, or earlier if they have a high risk of breast cancer and not all women. Women aged less than 30 years should undergo breast ultrasound instead.
Correct Answer is C
Explanation
Choice A rationale: A client with nausea, vomiting, and abdominal pain may have gastroenteritis, food poisoning, or appendicitis, which are not directly related to the eyes.
Choice B rationale: A client with chest tightness and heartburn may have gastroesophageal reflux disease (GERD), angina, or myocardial infarction (MI), which are also not associated with the eyes.
Choice C rationale: A client with facial drooping and left-sided weakness may have a stroke, which is a medical emergency that requires immediate attention. An eye examination can help detect signs of stroke, such as pupil asymmetry, visual field defects, or eye movement abnormalities. A stroke can cause permanent brain damage or death if not treated promptly.
Choice D rationale: A client with fatigue, fever, and productive cough may have a respiratory infection, such as pneumonia or tuberculosis, which are unlikely to affect the eyes unless there is a systemic complication.
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