Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is developing a plan of care for a client who has epilepsy and was admitted after experiencing a tonic-clonic seizure. Which of the following interventions should the nurse include in the plan?
A. Ensure padded wrist restraints are in the client's room.
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
B. Initiate IV access for the client.
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
C. Administer lorazepam every 4 hr to sedate the client.
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
D. Place an incontinence brief on the client
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
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Full Explanation
Choice A rationale:
Padded wrist restraints are not appropriate unless there's a clear clinical indication to prevent self-harm or injury.
Choice B rationale:
After a seizure, it's important to establish IV access for the client to administer medications, fluids, or other interventions if needed. Monitoring for possible postictal state, airway patency, and vital signs are also important components of care.
Choice C rationale:
Administering lorazepam every 4 hours is not a standard protocol for post-seizure management and could lead to excessive sedation.
Choice D rationale:
Placing an incontinence brief is not necessary unless there's a specific indication, and it doesn't directly relate to post-seizure care.
Similar Questions
A nurse is teaching the caregiver of a client who has Parkinson's disease. Which of the following instructions should the nurse include?
A. Allow the client extra time to perform ADLS.
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
B. Monitor the client for weight gain.
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
C. Instruct the client to look down at the feet when walking.
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
D. Provide the client with a low-protein diet.
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
Full Explanation
Choice A rationale:
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
Choice B rationale:
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
Choice C rationale:
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
Choice D rationale:
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
A nurse is assessing a client who has sickle cell anemia. Which of the following findings is the priority for the nurse to report?
A. Slurred speech
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
B. Yellowed sclera
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
C. Ulcers on the ankles
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
D. Swelling in the joints
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
Full Explanation
Choice A rationale:
Slurred speech could indicate a potential neurological complication in a client with sickle cell anemia, such as a stroke. Neurological symptoms require immediate attention and reporting to the healthcare provider.
Choice B rationale:
Yellowed sclera (jaundice) can be related to sickle cell anemia but is less acutely concerning than slurred speech.
Choice C rationale:
Ulcers on the ankles are often associated with sickle cell anemia, but they are not as urgent as neurological symptoms.
Choice D rationale:
Swelling in the joints is a potential manifestation of sickle cell anemia, but slurred speech indicates a more acute and concerning issue.
A nurse is reviewing the laboratory report of an 8-year-old child who has nephrotic syndrome. Which of the following laboratory results should the nurse report to the provider?
A. Sodium 140 mEq/L
The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.
B. Platelet count 350,000/mm3
The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.
C. Protein 2 g/dL
The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.
D. Cholesterol 170 mg/dL
The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.
Full Explanation
Choice A rationale:
The sodium level of 140 mEq/L is within the normal range for children, which is 135 to 145 mEq/L. Sodium levels may be low in nephrotic syndrome due to fluid retention and dilutional hyponatremia, but this is not the case for this child.
Choice B rationale:
The platelet count of 350,000/mm3 is within the normal range for children, which is 150,000 to 450,000/mm3. Platelet levels may be elevated in nephrotic syndrome due to increased production by the bone marrow in response to inflammation and infection, but this is not the case for this child.
Choice C rationale:
The nurse should report the protein level of 2 g/dL to the provider, as this is abnormally low and indicates severe proteinuria. Proteinuria is a hallmark of nephrotic syndrome, as the glomeruli become damaged and allow protein to leak into the urine. Normal protein levels for children are 6 to 8 g/dL. Low protein levels can lead to edema, hypoalbuminemia, and hyperlipidemia.
Choice D rationale:
The cholesterol level of 170 mg/dL is within the normal range for children, which is less than 200 mg/dL. Cholesterol levels may be high in nephrotic syndrome due to increased synthesis by the liver as a compensatory mechanism for low protein levels, but this is not the case for this child.