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Patient Data

Exhibits

To reduce the risk of recurrent seizures, which interventions should the nurse include in the client’s plan of care?

Administer anti-seizure medications as prescribed

Provide a quiet environment

Monitor blood glucose and electrolytes for abnormalities

Limit exposure to flashing lights

Encourage the client to engage in high-risk activities

Answer and Explanation

Correct Answer : A,B,C,D

Rationale for Correct Choices:

Administer anti-seizure medications as prescribed: Phenytoin and other anti-seizure medications help stabilize neuronal activity and prevent recurrence of seizures. Timely administration is critical in reducing seizure frequency and severity.
Provide a quiet environment: Excessive noise or stimulation can trigger seizures, especially in postictal or neurologically sensitive clients. A calm environment helps reduce stress and seizure risk.
Monitor blood glucose and electrolytes for abnormalities: Hypoglycemia, hyponatremia, or other electrolyte imbalances can precipitate seizures. Regular monitoring allows for early intervention to maintain neurological stability.
Limit exposure to flashing lights: Photosensitive clients are at risk for seizures triggered by flickering or flashing lights. Reducing exposure decreases the likelihood of recurrent seizure activity.

Rationale for Incorrect Choice:

Encourage the client to engage in high-risk activities: Activities that increase the risk of injury should be avoided for clients with seizure disorders. Promoting high-risk activities can result in trauma or harm during a seizure and is not appropriate for seizure prevention.

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Correct Answer is B

Explanation

Rationale:
A. Change the plan of care (POC) to include hourly urinary output measurements: Monitoring urinary output is important for overall fluid balance but does not directly address severe hypokalemia, which requires immediate correction.

B. Inform the healthcare provider (HCP) of the need for potassium replacement: A serum potassium level of 2.5 mEq/L is critically low and places the client at risk for life-threatening cardiac arrhythmias. Prompt notification allows the provider to prescribe urgent potassium replacement and prevent complications.

C. Prepare to administer a glucose, then insulin, then potassium infusion: This sequence is used to treat hyperkalemia, not hypokalemia. Administering insulin in this situation would worsen the potassium deficit.

D. Instruct the client to increase daily intake of potassium-rich foods: Dietary modification alone is insufficient for critically low potassium levels. Immediate pharmacologic replacement is necessary to restore safe potassium levels.

A. Urine is pale pink with no observable blood clots. B. Stone fragments are collected when straining the client's urine. C. Client denies urinary frequency, urgency, or dysuria. D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits.

Correct Answer is B

Explanation

Rationale:
A. Urine is pale pink with no observable blood clots: Light hematuria may occur after lithotripsy, but absence of clots alone does not confirm that the stones were effectively fragmented or removed.

B. Stone fragments are collected when straining the client's urine: The presence of stone fragments indicates that the lithotripsy successfully broke up the calculi, allowing them to pass or be collected. This directly demonstrates procedural effectiveness.

C. Client denies urinary frequency, urgency, or dysuria: Relief of urinary symptoms may occur gradually and does not immediately confirm that the stones were effectively fragmented or removed.

D. Serum creatinine and blood urea nitrogen (BUN) levels are within normal limits: Normal renal function is important, but it does not specifically indicate that the lithotripsy procedure successfully fragmented the stones.

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Patient Data Exhibits To reduce the risk of recurrent seizures, which interventions should the nurse include in the client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Correct Answer is B

Explanation

While assessing a client following lithotripsy with stent insertion, which data indicates to the nurse that the procedure was successful?

Correct Answer is B

Explanation

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse? Reference Range: Potassium (3.5 to 5 mEq/L (3.5 to 5 mmol/L)]

Patient Data Exhibits Complete the diagram below by indicating the potential condition of this client, actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

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While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?

Patient Data Exhibits Based on the nurse’s assessment, history and flow sheet, which condition is the client most likely experiencing?

Patient Data

Exhibits

To reduce the risk of recurrent seizures, which interventions should the nurse include in the client’s plan of care?