NUR 330 EXAM #4 NCLEX QUESTIONS AND CORRECT ANSWERS

NUR 330 EXAM #4 NCLEX
QUESTIONS AND CORRECT
ANSWERS
TheA2maleA2clientA2isA2sittingA2inA2theA2chairA2andA2hisA2entireA2bodyA2isA2rigidA2withA2hisA2
armsA2and
legsA2contractingA2andA2relaxing.A2TheA2clientA2isA2notA2awareA2ofA2whatA2isA2goingA2onA2a
ndA2isA2
makingA2gutturalA2sounds.A2WhichA2actionA2shouldA2theA2nurseA2implementA2first?
1.A2PushA2asideA2anyA2furniture.
2.A2PlaceA2theA2clientA2onA2hisA2side.
3.A2AssessA2theA2client'sA2vitalA2signs.
4.A2EaseA2theA2clientA2toA2theA2floor.
Company.A2KindleA2Edition.A2-A2Ans--4.A2TheA2clientA2shouldA2notA2remainA2inA2the
chairA2duringA2aA2seizure.A2HeA2shouldA2be
broughtA2safelyA2toA2theA2floorA2soA2thatA2he
willA2haveA2roomA2toA2moveA2theA2extremities.

TheA2occupationalA2healthA2nurseA2isA2concernedA2aboutA2preventingA2occupation-
relatedA2
acquiredA2seizures.A2WhichA2interventionA2shouldA2theA2nurseA2implement?
1.A2EnsureA2thatA2helmetsA2areA2wornA2inA2appropriateA2areas.
2.A2ImplementA2dailyA2exerciseA2programsA2forA2theA2staff.
3.A2ProvideA2healthyA2foodsA2inA2theA2cafeteria.
4.A2EncourageA2employeesA2toA2wearA2safetyA2glasses.A2-A2Ans--
1.A2HeadA2injuryA2isA2oneA2ofA2theA2mainA2reasons
forA2epilepsyA2thatA2canA2beA2prevented
throughA2occupationalA2safety
precautionsA2andA2highwayA2safety
programs.

TheA2clientA2isA2scheduledA2forA2anA2electroencephalogramA2(EEG)A2toA2helpA2diagnoseA2
a
seizureA2disorder.A2WhichA2preprocedureA2teachingA2shouldA2theA2nurseA2implement?
1.A2TellA2theA2clientA2toA2takeA2anyA2routineA2antiseizureA2medicationA2priorA2toA2theA2EEG
.
2.A2TellA2theA2clientA2notA2toA2eatA2anythingA2forA2eightA2(8)A2hoursA2priorA2toA2theA2proced
ure.
3.A2InstructA2theA2clientA2toA2stayA2awakeA2forA224A2hoursA2priorA2toA2theA2EEG.
4.A2ExplainA2toA2theA2clientA2thatA2thereA2willA2beA2someA2discomfortA2duringA2theA2proced
ure.A2-A2Ans--3.A2TheA2goalA2isA2forA2theA2clientA2toA2haveA2a
seizureA2duringA2theA2EEG.A2SleepA2deprivation,A2hyperventilating,A2orA2flashingA2lights
mayA2induceA2aA2seizure.

,TheA2nurseA2entersA2theA2roomA2asA2theA2clientA2isA2beginningA2toA2haveA2aA2tonic-
clonicA2seizure.
WhatA2actionA2shouldA2theA2nurseA2implementA2first?
1.A2NoteA2theA2firstA2thingA2theA2clientA2doesA2inA2theA2seizure.
2.A2AssessA2theA2sizeA2ofA2theA2client'sA2pupils.
3.A2DetermineA2ifA2theA2clientA2isA2incontinentA2ofA2urineA2orA2stool.
4.A2ProvideA2theA2clientA2withA2privacyA2duringA2theA2seizure.A2-A2Ans--
1.A2NoticingA2theA2firstA2thingA2theA2clientA2does
duringA2aA2seizureA2providesA2information
andA2cluesA2asA2toA2theA2locationA2ofA2the
seizureA2inA2theA2brain.A2ItA2isA2importantA2to
documentA2whetherA2theA2beginningA2of
theA2seizureA2wasA2observed.

TheA2clientA2whoA2justA2hadA2aA2threeA2(3)-
minuteA2seizureA2hasA2noA2apparentA2injuriesA2andA2is
orientedA2toA2name,A2place,A2andA2timeA2butA2isA2veryA2lethargicA2andA2justA2wantsA2toA2sl
eep.A2Which
interventionA2shouldA2theA2nurseA2implement?
1.A2PerformA2aA2completeA2neurologicalA2assessment.
2.A2AwakenA2theA2clientA2everyA230A2minutes.
3.A2TurnA2theA2clientA2toA2theA2sideA2andA2allowA2theA2clientA2toA2sleep.
4.A2InterviewA2theA2clientA2toA2findA2outA2whatA2causedA2theA2seizure.A2-A2Ans--
3.A2DuringA2theA2postictalA2(after-seizure)
phase,A2theA2clientA2isA2veryA2tiredA2and
shouldA2beA2allowedA2toA2restA2quietly;A2
placingA2theA2clientA2onA2theA2sideA2willA2help
preventA2aspirationA2andA2maintainA2a
patentA2airway.

TheA2unlicensedA2assistiveA2personnelA2(UAP)A2isA2attemptingA2toA2putA2anA2oralA2airwayA
2inA2the
mouthA2ofA2aA2clientA2havingA2aA2tonic-
clonicA2seizure.A2WhichA2actionA2shouldA2theA2primary
nurseA2take?
1.A2HelpA2theA2UAPA2toA2insertA2theA2oralA2airwayA2inA2theA2mouth.
2.A2TellA2theA2UAPA2toA2stopA2tryingA2toA2insertA2anythingA2inA2theA2mouth.
3.A2TakeA2noA2actionA2becauseA2theA2UAPA2isA2handlingA2theA2situation.
4.A2NotifyA2theA2chargeA2nurseA2ofA2theA2situationA2immediately.A2-A2Ans--
2.A2TheA2nurseA2shouldA2tellA2theA2UAPA2to
stopA2tryingA2toA2insertA2anythingA2inA2the
mouthA2ofA2theA2clientA2experiencingA2a
seizure.A2BrokenA2teethA2andA2injuryA2toA2theA2lipsA2andA2tongueA2mayA2resultA2from
tryingA2toA2placeA2anythingA2inA2the
clenchedA2jawsA2ofA2aA2clientA2havingA2a

, tonic-clonicA2seizure.

TheA2clientA2isA2prescribedA2phenytoinA2(Dilantin),A2anA2anticonvulsant,A2forA2aA2seizureA2
disorder.A2WhichA2statementA2indicatesA2theA2clientA2understandsA2theA2dischargeA2teach
ing
concerningA2thisA2medication?
1.A2"IA2willA2brushA2myA2teethA2afterA2everyA2meal."
2.A2"IA2willA2checkA2myA2DilantinA2levelA2daily."
3.A2"MyA2urineA2willA2turnA2orangeA2whileA2onA2Dilantin."
4.A2"IA2won'tA2haveA2anyA2seizuresA2whileA2onA2thisA2medication."A2-A2Ans--
1.A2ThoroughA2oralA2hygieneA2afterA2each
meal,A2gumA2massage,A2dailyA2flossing,A2
andA2regularA2dentalA2careA2areA2essential
toA2preventA2orA2controlA2gingival
hyperplasia,A2whichA2isA2aA2common
occurrenceA2inA2clientsA2takingA2
Dilantin.

TheA2clientA2isA2admittedA2toA2theA2intensiveA2careA2departmentA2(ICD)A2experiencingA2st
atus
epilepticus.A2WhichA2collaborativeA2interventionA2shouldA2theA2nurseA2anticipate?
1.A2AssessA2theA2client'sA2neurologicalA2statusA2everyA2hour.
2.A2MonitorA2theA2client'sA2heartA2rhythmA2viaA2telemetry.
3.A2AdministerA2anA2anticonvulsantA2medicationA2byA2intravenousA2push.
4.A2PrepareA2toA2administerA2aA2glucocorticosteroidA2orally.A2-A2Ans--
3.A2AdministeringA2anA2anticonvulsant
medicationA2byA2intravenousA2push
requiresA2theA2nurseA2toA2haveA2anA2orderA2or
conferA2withA2anotherA2memberA2ofA2the
health-careA2team.

TheA2clientA2hasA2beenA2newlyA2diagnosedA2withA2epilepsy.A2WhichA2dischargeA2instructi
ons
shouldA2beA2taughtA2toA2theA2client?A2SelectA2allA2thatA2apply.
1.A2KeepA2aA2recordA2ofA2seizureA2activity.
2.A2TakeA2tubA2bathsA2only;A2doA2notA2takeA2showers.
3.A2AvoidA2over-the-counterA2medications.
4.A2HaveA2anticonvulsantA2medicationA2serumA2levelsA2checkedA2regularly.
5.A2DoA2notA2driveA2alone;A2haveA2someoneA2inA2theA2car.A2-A2Ans--
1.A2KeepingA2aA2seizureA2andA2medicationA2chart
willA2beA2helpfulA2whenA2keepingA2follow-up
appointmentsA2withA2theA2health-care
providerA2andA2inA2identifyingA2activities
thatA2mayA2triggerA2aA2seizure.
3.A2Over-the-counterA2medicationsA2may
containA2ingredientsA2thatA2willA2interact