Question

o O Upright right lateral Dorsal recumbent with hyperextension of the neck 0 59. During reports, the previous nurse emphasized that one of the newly admitted patients is on seizure precautions, then income in nurse is correct when she performs which of the following actions to the clients? o move the patience to a room closer to the nurses station o maintain the clients bed in a lowest position O serve the client food in Paper and plastic containers o ensure that soft limb restraints are applied to upper extremities O 60.client is prescribed digoxin (Lanoxin) and for heart failure. The nurse should recognize that which of the following is a side effect of digxoxin toxicity bradycardia o hyperrеflеxia constipation 0 hypertension 61. The nurse visits a patient two days after cataract extraction and implant, which of the following statement if made by the patient requires further teaching? o I will call the doctor if I feel nauseous with Severe headache O my eyes itches is a little bit I think that means it's healing . I know I am not allowed to shampoo my hair for one year 0 I know I will have to have my husband lift anything heavier than 5 pounds for the next week 62. A client who has T6 spinal injury is experiencing autonomie dysreflexia, the nurse recognizes that which of the following possibly contributed to this condition? the client reports diarrhea for 24 hours. CO the clients bladder is distended The client has a temperature of 38.9°C (102 Fahrenheit) The client has chest congestion 63. During an extremely busy time during the shift. a middle-age Client is admitted to the unit with menorrhagia it is most important for the LPN/LVN to instruct the nursing assistance to perform which of the following activities? O asked the client if the vagina discharge has the decrease during the previous two hours measure vital signs Q8 hours if bleeding continues 0 reports the amount of vagina discharge the primary care physician 0 Collect the Clients soiled sanitary napkins in a plastic bag And give them to the LPN/LVN

Answer 1

59.A patient who has seizure is at risk of fall ,injury during an episode.The following precautions has to be taken in these type of patients they are

• Provide a safe environment where the patient during attack can not injure oneself
• Side railings should be always raised
• The bed has to be positioned in a low position
• The clothes of the patient shoul be loose because it can compress the patient when patiwnt experiences rigidity
• A side lying position is always recommended
• Head elevated with a pillow
• The patient always prefers a privacy

Ans:maintain the clients bed in a lowest position

60.The signs and symptoms of digoxin toxicity or its side effects areare

• Gastrointestinal :nausea,vomiting,pain in abdomen,anorexia,diarrhoea
• CNS:patient are confused, dizzy,headache,lack of awareness of the surrounding where they are
• Sensory: blurred vision ,yellow vision
• CVS: increased heart rate,ventricular fibrillation ,decreaed heart rate
• General :malaise,fatigue,weakness,rash

Ans:Bradycardia

61.The post post care in cataract implant are

• No heavy lifting by bending at least for 6 weeks
• Can take a bath below neck from the next day of surgery
• No headbath or shampooing for first 1 month of surgery
• Wear protective eye glasses
• In still eye drops as per order
• The vision may be blurted for few days and will be better as the days pass on

Ans:I know I am not allowed to shampoo my hair for one year

62.An autonomic dysreflexia can occur to a patient who has injury in the spinal cord at level 6 or above it ,this is always an emergent situation to treat the patient and protect from stroke.The major factors which can contribute to this are

• Injury to bladder,distended bladder ,infection
• Constipation,stool impaction,infection
• Bedsore at the sagital level
• Gastrointestinal ulcer
• Cyst formation in ovaries

Ans:distended bladder

63.Menorrhagia is a state in which patient has severe vaginal bleeding and can be fatal if not treated promptly.It is a LPN should inform to the physician and not the nursing assistant.Monitoring vital signs closely is very important to assess patient status at least one or two hourly till patient stabilises.

Ans:asked the client if the vaginal discharge has the decrease during the previous two hours