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A
The first priority during a seizure is to provide a safe environment, so the nurse should
clear the area (A) to reduce the risk of trauma. The child should not be restrained (B)
because this may cause more trauma. Objects should not be placed in the child's mouth
(C) because it may pose a choking hazard. Although (D) should be implemented after
the seizure, the nurse should not leave the child during a seizure to get help.
Give this one a try later!
A child is having a generalized tonic-clonic seizure. Which action should the
nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help.
,CDF
Correct responses are (C, D, and F). To maintain safety and to provide information, the
nurse should explain the potential benefits of continuing treatment in the hospital (C)
and the need to take prescribed medications (D). This client, who is very likely self-
destructive, should remain on the unit and the health care provider should be notified
(F). Signing a release form (A) before leaving the hospital does not contribute to safety.
The nurse may ask the client not to leave the hospital (B), but pressuring clients is
unethical behavior. (E) may be helpful at a later time in this client's treatment program.
Give this one a try later!
Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a
history of depression is hemodynamically stable but wants to leave the
hospital against medical advice. Which nursing action(s) is(are) most likely to
maintain client safety?
(Select all that apply.)
A.Direct the client to sign a liability release form.
B.Restrict the client's ability to leave the unit.
C.Explain the benefits of remaining in the hospital.
D.Instruct the client to take medications as prescribed.
E.Provide the client with names of local support groups.
F.Notify the health care provider of the client's intention.
D
The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be
discontinued gradually if necessary (B). Sometimes it is discontinued for a period of time
and then resumed at a higher dosage, and although (A) is partially correct, (D) is more
correct. Sometimes Symmetrel is given with other antiparkinsonian medications as an
adjunct, but (C) would have little effect.
Give this one a try later!
, A male client with Parkinson's disease has been taking the antiparkinsonian
agent amantadine HCl (Symmetrel) for 4 months. He tells the home health
nurse, "The medicine doesn't seem to be working anymore." Which information
should the nurse provide to this client?
A.The dosage probably needs to be increased.
B.The medication needs to be changed immediately.
C.The medication needs to be taken more frequently.
D.The effects of this drug tend to decrease after 3 months.
ABE
Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3
[triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of
hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-
stimulating hormone (TSH) are not therapeutic results from taking levothyroxine
(Synthroid) (B and C). Levothyroxine does not affect urine output (D).
Give this one a try later!
The nurse administers levothyroxine (Synthroid) to a client with
hypothyroidism. Which data indicate(s) that the drug is effective? (Select all
that apply.)
A.Increase in T3 and T4
B.Decrease in heart rate
C.Increase in TSH
D.Decrease in urine output
E.Decrease in periorbital edema
D
The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular
, sample, alters cytology analysis, and masks bacterial or sexually transmitted disease
infections, so the Pap test should be postponed (D). Although (A, B, and C) are indicated,
the client needs further teaching for the return visit to perform the Pap smear test.
Give this one a try later!
A female client arrives for an annual well-woman checkup and cervical Pap
test and tells the nurse that she has been using an over-the-counter (OTC)
vaginal cream for the past 2 days to treat an infection. Which initial response
should the nurse make?
A.Ask the client to describe the symptoms of the vaginal infection.
B.Assess if the client has been sexually active recently.
C.Tell the client to reschedule the examination in 1 week.
D.Inform the client that the scheduled Pap test cannot be done today.
D
A hearing-impaired client frequently relies on lip reading and body language to
determine what is being said, so (D) should be implemented. (A and C) may distort the
sounds and facial expressions, which alters the client's ability to interpret the verbal
message. Communicating in writing is another option that could be used if verbal or
body language is ineffective (B).
Give this one a try later!
An older client who resides in a long-term care facility is hearing-impaired.
How should the nurse modify interventions for this client?
A.Turn off the client's television and speak very loudly.
B.Communicate in writing whenever it is possible.
C.Speak very slowly while exaggerating each word.
D.Face the client and speak in a normal tone of voice.
A
The first priority during a seizure is to provide a safe environment, so the nurse should
clear the area (A) to reduce the risk of trauma. The child should not be restrained (B)
because this may cause more trauma. Objects should not be placed in the child's mouth
(C) because it may pose a choking hazard. Although (D) should be implemented after
the seizure, the nurse should not leave the child during a seizure to get help.
Give this one a try later!
A child is having a generalized tonic-clonic seizure. Which action should the
nurse take?
A.Move objects out of the child's immediate area.
B.Quickly slip soft restraints on the child's wrists.
C.Insert a padded tongue blade between the teeth.
D.Place in the recovery position before going for help.
,CDF
Correct responses are (C, D, and F). To maintain safety and to provide information, the
nurse should explain the potential benefits of continuing treatment in the hospital (C)
and the need to take prescribed medications (D). This client, who is very likely self-
destructive, should remain on the unit and the health care provider should be notified
(F). Signing a release form (A) before leaving the hospital does not contribute to safety.
The nurse may ask the client not to leave the hospital (B), but pressuring clients is
unethical behavior. (E) may be helpful at a later time in this client's treatment program.
Give this one a try later!
Two days after swallowing 30 tablets of alprazolam (Xanax), a client with a
history of depression is hemodynamically stable but wants to leave the
hospital against medical advice. Which nursing action(s) is(are) most likely to
maintain client safety?
(Select all that apply.)
A.Direct the client to sign a liability release form.
B.Restrict the client's ability to leave the unit.
C.Explain the benefits of remaining in the hospital.
D.Instruct the client to take medications as prescribed.
E.Provide the client with names of local support groups.
F.Notify the health care provider of the client's intention.
D
The beneficial effects of Symmetrel usually decrease in 3 to 6 months (D). It must be
discontinued gradually if necessary (B). Sometimes it is discontinued for a period of time
and then resumed at a higher dosage, and although (A) is partially correct, (D) is more
correct. Sometimes Symmetrel is given with other antiparkinsonian medications as an
adjunct, but (C) would have little effect.
Give this one a try later!
, A male client with Parkinson's disease has been taking the antiparkinsonian
agent amantadine HCl (Symmetrel) for 4 months. He tells the home health
nurse, "The medicine doesn't seem to be working anymore." Which information
should the nurse provide to this client?
A.The dosage probably needs to be increased.
B.The medication needs to be changed immediately.
C.The medication needs to be taken more frequently.
D.The effects of this drug tend to decrease after 3 months.
ABE
Levothyroxine is a thyroid replacement drug that increases thyroid hormone levels (T3
[triiodothyronine] and T4 [thyroxine]) and decreases periorbital edema, a symptom of
hypothyroidism (A and E). Decrease in heart rate and an increased level of thyroid-
stimulating hormone (TSH) are not therapeutic results from taking levothyroxine
(Synthroid) (B and C). Levothyroxine does not affect urine output (D).
Give this one a try later!
The nurse administers levothyroxine (Synthroid) to a client with
hypothyroidism. Which data indicate(s) that the drug is effective? (Select all
that apply.)
A.Increase in T3 and T4
B.Decrease in heart rate
C.Increase in TSH
D.Decrease in urine output
E.Decrease in periorbital edema
D
The over-the-counter (OTC) vaginal cream interferes with obtaining a cervical cellular
, sample, alters cytology analysis, and masks bacterial or sexually transmitted disease
infections, so the Pap test should be postponed (D). Although (A, B, and C) are indicated,
the client needs further teaching for the return visit to perform the Pap smear test.
Give this one a try later!
A female client arrives for an annual well-woman checkup and cervical Pap
test and tells the nurse that she has been using an over-the-counter (OTC)
vaginal cream for the past 2 days to treat an infection. Which initial response
should the nurse make?
A.Ask the client to describe the symptoms of the vaginal infection.
B.Assess if the client has been sexually active recently.
C.Tell the client to reschedule the examination in 1 week.
D.Inform the client that the scheduled Pap test cannot be done today.
D
A hearing-impaired client frequently relies on lip reading and body language to
determine what is being said, so (D) should be implemented. (A and C) may distort the
sounds and facial expressions, which alters the client's ability to interpret the verbal
message. Communicating in writing is another option that could be used if verbal or
body language is ineffective (B).
Give this one a try later!
An older client who resides in a long-term care facility is hearing-impaired.
How should the nurse modify interventions for this client?
A.Turn off the client's television and speak very loudly.
B.Communicate in writing whenever it is possible.
C.Speak very slowly while exaggerating each word.
D.Face the client and speak in a normal tone of voice.
