NURS 4 exam 5 practice answers
1. B. D. E.
Rational
e
Bite blocks or padded tongue blades should not be used because the
client's jaw may clench, causing teeth to break and possibly obstructing
the airway.
The client has been admitted with new-onset status epilepticus.
Which seizure precautions does the nurse put in place? Select all
that apply.
2. A.
Absence
Rationale
A. Absence seizures are more common in children and consist of brief
(often just seconds) periods of loss of consciousness and blank
staring, as though he or she is daydreaming.
B. Myoclonic seizures are characterized by brief jerking or
stiffening of the extremities, which may occur singly or in
groups.
C. Partial seizures are most often seen in adults.
D. Tonic seizures are characterized by an abrupt increase in muscle
tone, loss of consciousness, and autonomic changes lasting from 30
seconds to several minutes.
3. C. Assess the need for additional
support Rationale
A. Phenytoin (Dilantin) is administered to prevent the recurrence of
seizures, not to treat a seizure already under way.
B. Drawing blood is not the priority in this situation.
C. Convulsive status epilepticus must be treated promptly and
aggressively. After a quick assessment by the nurse, the health care
provider must be notified immediately, and intubation by an
anesthesiologist, nurse anesthetist, or respiratory therapist may be
necessary.
D. Starting an IV is not the priority in this situation.
4. D. Positions the client on the
side Rationale
A. Documenting the length and time of seizures is important, but
not while the seizure is occurring.
B. Forcing a tongue blade in the mouth can cause damage.
C. Restraining the client can cause injury.
D. Turning the client on the side during a generalized tonic-clonic
or complex partial seizure is indicated because he or she may lose
consciousness.
5. B. C. D.
Rational
e
Carbamazepine does not cause alopecia. Divalproex (Depakote)
and valproic acid (Depakene) may cause alopecia.
6. B. Young adult who has experienced four tonic-clonic seizures within
,the past 30 minutes
Rationale
A. This not a medical emergency and does not require immediate
attention.
B. This client is experiencing status epilepticus, which is a medical
emergency and requires immediate intervention.
, C. This is not a medical emergency and does not require immediate
attention.
D. A fever of 101.9° F (38.8° C) is not a medical emergency and does
not require immediate attention.
7. C. Grapefruit
juice Rationale
A. Apple juice does not interact with phenytoin.
B. Grape juice does not interact with phenytoin.
C. Grapefruit juice can interfere with the metabolism of phenytoin.
D. Milk does not interact with phenytoin.
8. B. D. E.
Rationale
Clients placed on seizure precautions should have an oxygen setup,
suction equipment, and an artificial oral airway at the bedside.
Maintaining a patent airway is the priority for this client's care.
Intubation by an anesthesia provider or respiratory therapist may be
necessary. Oxygen may need to be administered as indicated by the
client's condition. Padded tongue blades do not belong at the bedside
and should NEVER be inserted into the client's mouth because the jaw
may clench down as soon as the seizure begins. Forcing a tongue
blade or airway into the mouth is more likely to chip the teeth and
increase the risk of aspirating tooth fragments than prevent the client
from biting the tongue.
Furthermore, improper placement of a padded tongue blade can
obstruct the airway. There is no physiologic reason to place a
nasogastric tube emergently for a client experiencing seizure activity.
In fact, convulsions may make it difficult to place the tube and put the
client at risk.
9. B
10. A
11. C
12. C
13. D
14. C. D E.
Rationale: The client should avoid standing or sitting for long periods of time because
this can cause further strain on the back.
15. D. Positioning the client to maximize ventilation potential
Rationale: Airway management is the priority for the client with a spinal cord injury.
16. D. Respiratory therapy
Rationale: Pneumonia, pulmonary emboli, and atelectasis have replaced kidney failure as
the leading causes of death in clients with spinal cord injury. Respiratory therapy helps
prevent complications such as these from arising.
17. A. Gel pad
Rationale: In addition to regular turning and repositioning, special pressure relief devices
such as gel pads may be used in the wheelchair or bed to prevent pressure ulcers in the
client with spinal cord injury.
18. C. "I may still be able to get pregnant."
Rationale: Many people with spinal cord injury go on to get pregnant and give birth to
healthy children.
, 19. A. "I can go home the day of the procedure."
Rationale: The client who undergoes a microdiskectomy typically can return home
the same day.
20. A. Patent airway
Rationale: Clients with injuries at or above T6 are at risk for respiratory complications.
21. C. Sensation
Rationale: Both extremities may be checked for sensation by using a pin or paper clip and
a cotton ball for comparison of light and deep touch. The client may feel sensation in
both limbs but may experience a stronger sensation on the unaffected side.
22. C. Regular turning and repositioning
Rationale: Regular turning and repositioning is the best way to prevent complications of
immobility in clients with spinal cord health problems.
23. D. Log rolling the client
Rationale: Log rolling the client who has undergone spinal surgery is the best way
to keep the spine in alignment.
24. D. Keep straws available for drinking fluids.
Rationale: Keeping straws available makes it easier to drink fluids because the device
makes it difficult to bring a cup or a glass to the mouth.
25. A. "It should help return bladder control."
Rationale: Surgical decompression may be performed to maintain bladder, bowel,
or motor function and to preserve quality of life, even with a poor prognosis.
26. B. Hydralazine (Apresoline)
Rationale:B. This client is experiencing autonomic dysreflexia, which is
a neurologic medical emergency that causes severe hypertension and
bradycardia. Hydralazine (Apresoline) is an antihypertensive drug used
to treat autonomic dysreflexia.
A. Dopamine hydrochloride (Inotropin) is an inotropic agent used to
treat severe hypotension.
C. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not
indicated because it may further increase blood pressure.
D. Ziconotide (Prialt) is an N-type calcium channel blocker that is
used to treat severe chronic back pain and failed back surgery
syndrome (FBSS)
27. B. The client has hoarseness and some difficulty swallowing
secretions. The client has numbness and tingling bilaterally down
the arms.
Rationale: Hoarseness and difficulty swallowing may indicate swelling
in the neck and the potential for compromise of the client's airway.
The other findings are expected after this surgery.
28. C. The client's chest moves very little with each respiration.
Rationale: Airway and breathing are always of major concern in a spinal cord injury,
especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.
Symptoms often worsen after injury because of swelling.
29. C. Help the client sit up.
Rationale: The client is experiencing autonomic dysreflexia, which can
produce severe and rapidly occurring hypertension. Getting the client to
sit upright is the
1. B. D. E.
Rational
e
Bite blocks or padded tongue blades should not be used because the
client's jaw may clench, causing teeth to break and possibly obstructing
the airway.
The client has been admitted with new-onset status epilepticus.
Which seizure precautions does the nurse put in place? Select all
that apply.
2. A.
Absence
Rationale
A. Absence seizures are more common in children and consist of brief
(often just seconds) periods of loss of consciousness and blank
staring, as though he or she is daydreaming.
B. Myoclonic seizures are characterized by brief jerking or
stiffening of the extremities, which may occur singly or in
groups.
C. Partial seizures are most often seen in adults.
D. Tonic seizures are characterized by an abrupt increase in muscle
tone, loss of consciousness, and autonomic changes lasting from 30
seconds to several minutes.
3. C. Assess the need for additional
support Rationale
A. Phenytoin (Dilantin) is administered to prevent the recurrence of
seizures, not to treat a seizure already under way.
B. Drawing blood is not the priority in this situation.
C. Convulsive status epilepticus must be treated promptly and
aggressively. After a quick assessment by the nurse, the health care
provider must be notified immediately, and intubation by an
anesthesiologist, nurse anesthetist, or respiratory therapist may be
necessary.
D. Starting an IV is not the priority in this situation.
4. D. Positions the client on the
side Rationale
A. Documenting the length and time of seizures is important, but
not while the seizure is occurring.
B. Forcing a tongue blade in the mouth can cause damage.
C. Restraining the client can cause injury.
D. Turning the client on the side during a generalized tonic-clonic
or complex partial seizure is indicated because he or she may lose
consciousness.
5. B. C. D.
Rational
e
Carbamazepine does not cause alopecia. Divalproex (Depakote)
and valproic acid (Depakene) may cause alopecia.
6. B. Young adult who has experienced four tonic-clonic seizures within
,the past 30 minutes
Rationale
A. This not a medical emergency and does not require immediate
attention.
B. This client is experiencing status epilepticus, which is a medical
emergency and requires immediate intervention.
, C. This is not a medical emergency and does not require immediate
attention.
D. A fever of 101.9° F (38.8° C) is not a medical emergency and does
not require immediate attention.
7. C. Grapefruit
juice Rationale
A. Apple juice does not interact with phenytoin.
B. Grape juice does not interact with phenytoin.
C. Grapefruit juice can interfere with the metabolism of phenytoin.
D. Milk does not interact with phenytoin.
8. B. D. E.
Rationale
Clients placed on seizure precautions should have an oxygen setup,
suction equipment, and an artificial oral airway at the bedside.
Maintaining a patent airway is the priority for this client's care.
Intubation by an anesthesia provider or respiratory therapist may be
necessary. Oxygen may need to be administered as indicated by the
client's condition. Padded tongue blades do not belong at the bedside
and should NEVER be inserted into the client's mouth because the jaw
may clench down as soon as the seizure begins. Forcing a tongue
blade or airway into the mouth is more likely to chip the teeth and
increase the risk of aspirating tooth fragments than prevent the client
from biting the tongue.
Furthermore, improper placement of a padded tongue blade can
obstruct the airway. There is no physiologic reason to place a
nasogastric tube emergently for a client experiencing seizure activity.
In fact, convulsions may make it difficult to place the tube and put the
client at risk.
9. B
10. A
11. C
12. C
13. D
14. C. D E.
Rationale: The client should avoid standing or sitting for long periods of time because
this can cause further strain on the back.
15. D. Positioning the client to maximize ventilation potential
Rationale: Airway management is the priority for the client with a spinal cord injury.
16. D. Respiratory therapy
Rationale: Pneumonia, pulmonary emboli, and atelectasis have replaced kidney failure as
the leading causes of death in clients with spinal cord injury. Respiratory therapy helps
prevent complications such as these from arising.
17. A. Gel pad
Rationale: In addition to regular turning and repositioning, special pressure relief devices
such as gel pads may be used in the wheelchair or bed to prevent pressure ulcers in the
client with spinal cord injury.
18. C. "I may still be able to get pregnant."
Rationale: Many people with spinal cord injury go on to get pregnant and give birth to
healthy children.
, 19. A. "I can go home the day of the procedure."
Rationale: The client who undergoes a microdiskectomy typically can return home
the same day.
20. A. Patent airway
Rationale: Clients with injuries at or above T6 are at risk for respiratory complications.
21. C. Sensation
Rationale: Both extremities may be checked for sensation by using a pin or paper clip and
a cotton ball for comparison of light and deep touch. The client may feel sensation in
both limbs but may experience a stronger sensation on the unaffected side.
22. C. Regular turning and repositioning
Rationale: Regular turning and repositioning is the best way to prevent complications of
immobility in clients with spinal cord health problems.
23. D. Log rolling the client
Rationale: Log rolling the client who has undergone spinal surgery is the best way
to keep the spine in alignment.
24. D. Keep straws available for drinking fluids.
Rationale: Keeping straws available makes it easier to drink fluids because the device
makes it difficult to bring a cup or a glass to the mouth.
25. A. "It should help return bladder control."
Rationale: Surgical decompression may be performed to maintain bladder, bowel,
or motor function and to preserve quality of life, even with a poor prognosis.
26. B. Hydralazine (Apresoline)
Rationale:B. This client is experiencing autonomic dysreflexia, which is
a neurologic medical emergency that causes severe hypertension and
bradycardia. Hydralazine (Apresoline) is an antihypertensive drug used
to treat autonomic dysreflexia.
A. Dopamine hydrochloride (Inotropin) is an inotropic agent used to
treat severe hypotension.
C. Methylprednisolone (Solu-Medrol) is a glucocorticoid and is not
indicated because it may further increase blood pressure.
D. Ziconotide (Prialt) is an N-type calcium channel blocker that is
used to treat severe chronic back pain and failed back surgery
syndrome (FBSS)
27. B. The client has hoarseness and some difficulty swallowing
secretions. The client has numbness and tingling bilaterally down
the arms.
Rationale: Hoarseness and difficulty swallowing may indicate swelling
in the neck and the potential for compromise of the client's airway.
The other findings are expected after this surgery.
28. C. The client's chest moves very little with each respiration.
Rationale: Airway and breathing are always of major concern in a spinal cord injury,
especially in an injury near C3 to C5, where the spinal nerves control the diaphragm.
Symptoms often worsen after injury because of swelling.
29. C. Help the client sit up.
Rationale: The client is experiencing autonomic dysreflexia, which can
produce severe and rapidly occurring hypertension. Getting the client to
sit upright is the
