Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse enters the room of a school-age child and finds them on the floor experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
A. Turn the child onto their back.
It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.
B. Restrain the child's upper extremities.
Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.
C. Place a padded tongue blade in the child's mouth.
Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.
D. Place a pillow under the child's head.
The correct action to take in this situation is to place a pillow or cushion under the child's head. This will help protect the child from injuring their head during the seizure.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
The correct action to take in this situation is to place a pillow or cushion under the child's head.
This will help protect the child from injuring their head during the seizure.
It is important not to turn the child onto their back during a seizure, as this can obstruct the airway and potentially lead to respiratory distress.
Restraining the child's upper extremities is also not recommended, as it can cause injury to the child or the person trying to restrain them.
Placing a padded tongue blade or any object in the child's mouth is no longer recommended during a seizure. Doing so can cause injury to the child's mouth or teeth and is not necessary for seizure management.
Similar Questions
A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?
A. Restrict the client's sodium intake to 3 g per day.
Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. Position the client supine with legs elevated.
This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. Measure the client's abdominal girth daily.
This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. Keep the client's daily protein intake below 0.8 g/kg.
While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.
Full Explanation
A. Sodium restriction is a key component in the management of ascites, as it helps to reduce fluid retention. However, the standard recommendation for sodium intake in ascites management is typically lower than 3 grams per day. The guideline is often around 2 grams or even less to effectively manage ascites. Thus, while the concept is correct, the specific amount in this option is slightly higher than usually recommended.
B. This is not generally recommended for clients with ascites. Lying flat can increase discomfort and pressure on the diaphragm, making breathing more difficult. Instead, positioning the client in a semi-Fowler's or Fowler's position can help alleviate respiratory distress by reducing pressure on the diaphragm.
C. This is a crucial intervention. Measuring abdominal girth daily provides a reliable way to monitor changes in the size of the abdomen, which reflects changes in the amount of ascitic fluid. It helps in assessing the effectiveness of treatment and detecting any rapid accumulation of fluid that might require intervention.
D. While protein restriction was traditionally recommended to prevent hepatic encephalopathy, more recent guidelines suggest that moderate protein intake should be maintained unless the client has severe hepatic encephalopathy. Adequate protein intake is necessary to prevent muscle wasting and support liver function, and it should generally be individualized based on the client’s condition.
A nurse is monitoring a client who has received external radiation for throat cancer. Which of the following findings should the nurse expect?
A. Loss of taste
Radiation therapy can affect the taste buds, leading to a diminished or altered sense of taste. This can result in a reduced appetite or changes in food preferences.
B. Loose stools
Loose stools and bladder infection are not commonly associated with external radiation for throat cancer. Loose stools can be a side effect of radiation therapy to the abdomen or pelvis, but it is not typically seen in throat cancer treatment.
C. increased appetite
Increased appetite is also not a typical finding associated with radiation therapy, as it may cause side effects such as nausea or changes in taste, which can decrease appetite.
D. Bladder infection
Bladder infection is not directly related to radiation therapy, but it can occur as a complication in some individuals undergoing cancer treatment, especially if they have a compromised immune system.
Full Explanation
Radiation therapy can affect the taste buds, leading to a diminished or altered sense of taste.
This can result in a reduced appetite or changes in food preferences.
Loose stools and bladder infection are not commonly associated with external radiation for throat cancer. Loose stools can be a side effect of radiation therapy to the abdomen or pelvis, but it is not typically seen in throat cancer treatment.
Bladder infection is not directly related to radiation therapy, but it can occur as a complication in some individuals undergoing cancer treatment, especially if they have a compromised immune system.
Increased appetite is also not a typical finding associated with radiation therapy, as it may cause side effects such as nausea or changes in taste, which can decrease appetite
A nurse is administering pancrelipase to a child who has cystic fibrosis. Which of the following outcomes should the nurse expect as a therapeutic effect of the treatment?
A. Improved respiratory function
Pancrelipase does not directly impact respiratory function. It is an enzyme replacement therapy used to aid digestion by compensating for the lack of pancreatic enzymes, not to improve lung function.
B. Decreased sodium excretion
Cystic fibrosis affects sodium and chloride transport, leading to higher sodium levels in sweat. However, pancrelipase does not affect sodium excretion; it focuses on aiding digestion.
C. Improved absorption of vitamins B and C
Pancrelipase helps with the digestion and absorption of fats and fat-soluble vitamins (A, D, E, K). Vitamins B and C are water-soluble and are not typically affected by the enzyme therapy used for fat digestion.
D. Reduced fat in the stools
This is the correct answer. Pancrelipase contains enzymes (lipase, protease, and amylase) that help break down fats, proteins, and carbohydrates. In cystic fibrosis, pancreatic enzyme production is often insufficient, leading to malabsorption and steatorrhea (excessive fat in the stools). By providing the necessary enzymes, pancrelipase helps improve the digestion and absorption of dietary fats, reducing the fat content in the stools.
Full Explanation
a. Pancrelipase does not directly impact respiratory function. It is an enzyme replacement therapy used to aid digestion by compensating for the lack of pancreatic enzymes, not to improve lung function.
b. Cystic fibrosis affects sodium and chloride transport, leading to higher sodium levels in sweat. However, pancrelipase does not affect sodium excretion; it focuses on aiding digestion.
c. Pancrelipase helps with the digestion and absorption of fats and fat-soluble vitamins (A, D, E, K). Vitamins B and C are water-soluble and are not typically affected by the enzyme therapy used for fat digestion.
d. This is the correct answer. Pancrelipase contains enzymes (lipase, protease, and amylase) that help break down fats, proteins, and carbohydrates. In cystic fibrosis, pancreatic enzyme production is often insufficient, leading to malabsorption and steatorrhea (excessive fat in the stools). By providing the necessary enzymes, pancrelipase helps improve the digestion and absorption of dietary fats, reducing the fat content in the stools.