While assisting a female client to the toilet, the client begins to have a seizure and the nurse eases her
to the floor. The nurse calls for help and monitors the client until the seizing stops. Which intervention
should the nurse implement first?
Document details of the seizure activity
,Observe for lacerations to the tongue
Observe for prolonged periods of apnea
Evaluate for evidence of incontinence: C. Observe for prolonged periods of apnea
A male client with diabetes mellitus (DM) is transferred from the hospital to a rehabilitation facility
following treatment for a stroke with resulting right hemiplegia. He tells the nurse that his feet are
always uncomfortably cool at night, preventing him from falling asleep. Which action should the nurse
implement.
Provide a warming pad (Aqua-pad or K-pad) to feet
Medicate the client with a prescribed sedative
Use a bed cradle to hold the covers off the feet
Place warm blankets next to the client's feet: D. Place warm blankets next to the client's feet
During a home visit, the nurse assesses the skin of a client with eczema who reports that an
exacerbation of symptoms has occurred during the last week. Which information is most useful in
determining the possible cause of the symptoms?
An old friend with eczema came for a visit
,Recently received an influenza immunization
A grandson and his new dog recently visited
Corticosteroid cream was applied to eczema: C. A grandson and his new dog recently visited
While planning care for a client with carpal tunnel syndrome, the nurse identifies a collaborative
problem of pain. what is the etiology of this prob- lem?
Irritation of nerve endings
Diminished blood flow
Ischemic tissue changes
Compression of a nerve: D. Compression of a nerve
The nurse assesses a client being treated for Herpes Zoster (shingles). Which assessments should the
nurse include when evaluating the effective- ness of treatment? (Select all that apply)
Skin integrity
, Functional ability
Heart sounds
Pain scale
Bowel sounds: A. Skin integrity
B. Functional ability
D. Pain scale
A male client tells the clinic nurse that he is experiencing burning on uri- nation, and assessment
reveals that he had sexual intercourse four days ago with a woman he casually met. Which action
should the nurse implement?
Observe the perineal area for a chancroid-like lesion
Obtain a specimen of urethral drainage for culture
Assess for perineal itching, erythema and excoriation
Identify all sexual partners in the last four days: B. Obtain a specimen of urethral drainage for culture
A client with Addison's disease started taking hydrocortisone in a divided daily dose last week. It is
most important for the nurse to monitor which serum laboratory value?