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 B
Explanation
Choice A rationale: This is not accurate since the manifestations of facial nerve paralysis are observed on the contralateral side which in this case is the left side of the face hence the right facial nerve is paralyzed.
Choice B rationale: Facial nerve paralysis cause symptoms such as drooping of the eyelid, cheek or mouth as depicted in the above picture. The right facial nerve is paralyzed since the nerve innervates the contralateral side hence the effects are demonstrated on the
left side of the face.
Choice C rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
Choice D rationale: trigeminal nerve paralysis causes symptoms such as weakness in muscles of mastication, altered sensation over the face and tongue, and hearing impairment and not the symptoms depicted above.
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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