Chapter 04: Patient Safety and Quality Improvement

Multiple Choice

1. The nurse is caring for an older patient who has a non–weight-bearing cast on the left lower extremity. The patient ambulates without using a walker despite repeated instruction from the nurse to call for assistance. Which response by the nurse is most likely to keep the patient from falling?

a. Apply a vest restraint and offer frequent toileting.

b. Plan fall prevention with patient, family, and health care provider.

c. Inform family that the patient needs physical restraints.

d. Document that the patient has a high potential for falling.

ANS: B

Planning an individualized fall prevention program with the help of the patient, family, and health care provider is more likely to reduce the patient’s risk of falls because the patient gains some control over the plan of care and still benefits from the input of the provider, family, and nurse. A combination of interventions is more useful in preventing falls. Including the patient in planning also gives him or her ownership of the plan, making it less likely the patient will disregard this plan. Restraints are associated with serious injuries and are not recommended for use unless nothing else has worked. Alternative methods of engaging the patient in a care plan that minimizes risks should be exhausted before resorting to restraints. Documenting the patient’s risk is important because it communicates the information and records the nurse’s acknowledgment of the risk, but it is not as effective as engaging the patient in planning care as a prevention technique because it is indirect.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Evaluating patient understanding of fall prevention plan b. Keeping the patient’s bed in the low position at all times c. Assessing the patient’s circulatory and respiratory status d. Instructing the patient’s family about alternatives to restraints

2. The nurse plans a fall prevention program for a confused patient. Which task from the program is suitable for the nurse to delegate to nursing assistive personnel (NAP)?

ANS: B

The nurse may delegate keeping the bed lowered to the NAP because the NAP is trained to perform the task with proper nursing supervision. Skills used to prevent falls can often be delegated. The nurse does not delegate the remaining options because they involve aspects of the nursing process that require the advanced training of a nurse to perform.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. The patient remains free of any injury. b. The nurse checks the restraint every hour. c. The nurse uses the least restrictive restraint. d. The patient allows the nurse to apply restraints.

3. The nurse plans care for a patient who requires physical restraint. Which is a suitable goal for this patient?

ANS: A

When restraints become necessary, the patient must remain free of injury; thus the nurse plans frequent neurovascular checks and removes the restraint on a regular basis to inspect the skin for pressure points and breakdown and perform range-of-motion exercises to maintain joint flexibility. Checking the restraint is a nursing intervention; it is not a goal because it is not patient centered. Using the least restrictive restraint can defeat the purpose of a restraint. When a restraint is required, the nurse uses the proper restraint to keep the patient safe and facilitate the therapeutic regimen. This is not a suitable goal because it focuses on the nurse. If the patient or staff members’ safety is at risk, the nurse applies restraints without the patient’s permission.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Performed restraint application reluctantly b. Applied bilateral soft lamb’s wool wrist restraints; skin pink, moist, and intact c. Will perform a neurovascular assessment every 4 hours d. Checked provider’s prescription for prn restraints

4. The nurse applies a physical restraint to the patient. Which entry should the nurse make after applying the restraint?

ANS: B

The nurse documents the type of restraint applied and the condition of the skin where the restraint was placed in the progress notes to communicate the information to the health care team. The nurse does not document subjective statements about the nurse. Neurovascular assessments of a patient’s extremity must take place at least every 2 hours because skin breakdown can occur very quickly. The nurse does not accept prn prescriptions for restraints according to nursing standards and federal regulations.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Integrated Process: Communication and Documentation a. Type of muscle contractions b. Size and description of the abrasion c. Length of the patient’s apneic episode d. Description of the seizure in detail

5. The patient sustains a minor leg abrasion and stops breathing for a few seconds during a tonic-clonic seizure. Which is the best nursing documentation after the patient’s seizure?

ANS: D

Describing the seizure in detail is the best documentation after a seizure because it is the most comprehensive item listed and includes the type of muscle contractions observed during the seizure, the description of injuries, how the injuries occurred, and the description of any breathing abnormalities.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Integrated Process: Communication and Documentation a. Raising the bed to an appropriate working height b. Placing nonskid shoes on the patient c. Dangling the patient on the side of the bed for 10 minutes d. Turning on the brightest lights in the room

6. A patient at risk for falling is being ambulated. Which action by the nurse is most important to prevent the patient from falling?

ANS: B

Placing nonskid surfaces on the patient’s feet helps to prevent falls. The height of the bed should be as low as possible before attempting to have the patient stand. Dangling prevents dizziness, but the length of time differs, and it is not required for all patients. Adequate light is important, but the brightest lights are not needed.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Medication errors b. Falls c. Communication failures d. High patient-to-nurse ratios

7. The nurse is orienting a group of new nurses and explaining the concept of sentinel events and their causes. What should the nurse explain as a common root cause of all sentinel event?

ANS: C

Communication failures are one of the most common root causes of all sentinel events. A sentinel event is an unexpected occurrence involving death, serious physical or psychological injury, or risk thereof. Although the other elements may cause sentinel events, they are not as frequent as communication failures.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Integrated Process: Communication and Documentation a. Find the fire extinguisher and try to extinguish the fire. b. Evacuate the entire second floor to the first-floor lobby. c. Rescue any patients, visitors, or staff in immediate danger. d. Pull the nearest alarm box and call the telephone operator.

8. The nurse discovers smoke in the second-floor utility room. What intervention should he or she implement first?

ANS: C

The first step after identifying an actual or potential fire is to rescue victims at risk for injury from the fire, including patients, visitors, or staff, to reduce injuries from the fire. The second step is to activate the alarm. The third step is to contain the fire: find the extinguisher and empty the container onto the fire or source of the smoke. Finally the evacuation begins if the fire is uncontrolled or the smoke is excessive. This follows the acronym RACE.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Ask the patient why she does not use the nurse call system. b. Instruct the daughter to remain at the patient’s side. c. Tell the patient that getting up requires cooperation. d. Discuss nurse call system alternatives with patient and daughter.

9. The daughter of a patient tells the nurse that using the bathroom is embarrassing for the patient and she refuses to use a nurse call system when she needs to get up. Which is the best response by the nurse?

ANS: D

Discussing nurse call system alternatives with the patient and daughter is the best method of engaging the patient in planning nursing care. This recognizes the patient as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient’s preferences, values, and needs. Including the patient in planning alternatives also gives him or her ownership of the plan and increases the likelihood of cooperation. Asking a “why” question is not an ideal response because it is confrontational and requires the patient to justify feelings. Remaining with the patient is an impractical solution.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. The nurse b. Housekeeping c. Nursing assistive personnel (NAP) d. The maintenance department

10. Although the interdisciplinary team is responsible for the safety of the patient, who has the ultimate responsibility for making the patient’s bedside area safe?

ANS: A

The nurse has the ultimate responsibility for making the patient’s bedside area safe. Other personnel assist with their specific roles, but the nurse oversees the safety.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. No, because personal items can increase patient agitation. b. No, because personal items can create too much clutter. c. Yes, personal items are likely to restore cognitive function. d. Yes, personal items can comfort a confused person.

11. The nurse listens to a family’s request to bring a few familiar items into the room of a patient who is confused. What response by the nurse is best?

ANS: D

Personal items can comfort and calm a confused person because familiar items are part of the patient’s customary environment, patterns, and habits; in addition, these items personalize an otherwise strange environment and surround the patient with recognizable things. The personal items are likely to engage the patient but on their own do nothing to restore cognitive function.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Request help from interdisciplinary team members. b. Transfer the patient to a private room to protect others. c. Document that the patient is uncooperative and hostile. d. Ask the health care provider for a sedation prescription.

12. The nurse plans a restraint-free environment but cannot find activities to engage an agitated middle-aged patient. Which should the nurse implement to maintain the patient’s safety?

ANS: A

A nurse’s expertise does not include all facets of health care, so the nurse collaborates with other experts to meet the patient’s safety and psychosocial needs. After assessing the patient, the experts make recommendations, and the nurse incorporates the activities into the patient’s plan of care. Putting the patient in a private room decreases the risk of injury to other patients; but it isolates the patient, increases the need for distraction, and increases the risks to the staff and patient. Documentation should always be descriptive and never judgmental. In this case the nurse would document the patient’s own words in quotation marks. Sedation increases the risk of falls from potential adverse effects, including hypotension, dizziness, and confusion.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Use nonprescription restraints first. b. Obtain with a telephone prescription. c. Implement alternative measures first. d. Notify patient’s family within 24 hours.

13. A patient has been wandering and is at risk for falling. Which approach by the nurse regarding the use of chemical and physical restraints in the long-term care setting should be considered initially?

ANS: C

According to the standards governing the use of restraints, the nurse must implement several alternative measures in a serious attempt to avoid applying restraints. The patient must be assessed by the health care provider before restraints are implemented unless the patient is a serious and imminent risk to self and others. The patient’s family is notified in a timely manner but is not an initial consideration.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. A 79-year-old after a pacemaker battery replacement b. A 68-year-old anemic patient who is dehydrated and has heart failure c. A 21-year-old 2 hours postarthroscopy after a college football injury d. A 33-year-old patient post–right salpingectomy for ectopic pregnancy

14. The nurse plans a safety program for the patients on a medical-surgical unit. Which patient has the greatest likelihood of falling?

ANS: B

The patient with anemia and dehydration with heart failure is the sickest patient and has the highest risk of falling. The patient will be taking other medications, including antihypertensive agents that increase the risk of falls caused by confusion, dizziness, or orthostatic hypotension. The replacement of a pacemaker battery in a stable patient is a low-risk, routine procedure. The 21-year-old recovering from the arthroscopy is most likely a healthy adult who is stable while ambulating. The 33-year-old postsalpingectomy is most likely to be healthy but may be a little hypotensive if much bleeding occurred before surgery or from side effects of analgesia.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Assessment a. Cover or camouflage tubes and drains. b. Provide constant activity for the patient. c. Instruct family members to watch the patient. d. Keep the patient close to the nurses’ station.

15. The nurse finds the patient pulling on the nasogastric tube (NGT) and surgical drain and fears that the patient will pull them out. Which nursing intervention should the nurse implement to maintain the patient’s self-esteem and avoid applying restraints?

ANS: A

Covering the medical devices is a good intervention. If the patient cannot see them, he or she will be less likely to fidget with them. The nurse most likely will not be able to provide constant activity for the patient. That strategy may also fatigue the patient. Engaging the family in the care of the patient is reasonable; however, the nurse does not rely on the family to provide nursing care. Keeping the patient out by the nurses’ station allows the nurse to observe the patient closely; however, this is likely to lower the patient’s self-esteem because his or her problem is on public display and not all patients are stable enough to do so.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Notify the provider quickly. b. Remove the wrist restraints. c. Try another type of restraint. d. Increase the restraint padding.

16. The patient wearing bilateral wrist restraints complains hand numbness, and the nurse assesses pale, cool fingers. Which is the nurse’s priority intervention?

ANS: B

The patient displays clinical indicators of neurovascular impairment, and a delay in resolving the problem can result in tissue damage, so the nurse removes the restraint, thoroughly assesses the extremities, and plans nursing care. Before another type of restraint is applied, the nurse completes the assessment and notifies the provider as necessary. Increasing the padding may be a reasonable intervention after the nurse’s assessment and provider notification.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Apply chin-lift position. b. Insert a curved oral airway. c. Sit the patient in upright position. d. Turn the patient to the side.

17. The patient is having a generalized tonic-clonic seizure. To maintain the airway, which intervention should the nurse implement after the patient’s motor activity ceases?

ANS: D

After the seizure has ended, position the patient on the side to prevent aspiration. Chin-lift is an effective method of maintaining a patient’s airway; however, it does not protect the patient against aspiration. Oral airways are not inserted during a seizure unless the patient’s jaw relaxes enough to properly insert the airway without causing tissue damage. The upright position is contraindicated for airway maintenance.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Avoiding substances containing alcohol b. Maintaining a current list of medications c. Keeping a supply of medications at work d. Purchasing lawn equipment with a safety switch

18. The nurse is instructing a patient who has a difficult-to-control seizure disorder on home care issues. Which issue affecting safety is most important for the nurse to address with patient teaching before discharge?

ANS: D

The most important issue to address is to have the patient purchase any motorized lawn equipment with a safety switch that will stop the machine when the handle is released. Thus the patient avoids injury if he has a seizure while operating the equipment. Although the patient should avoid alcohol to decrease the risk of possible alcohol-drug interactions, and should keep a list of current medications to avoid confusion over the therapeutic regimen, failure to do so poses a lesser risk than using motorized equipment if a seizure occurs. Likewise, although keeping a supply of medication at work is a good idea, it is not a safety risk not to do so.

DIF: Cognitive Level: Analyzing OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. A jacket restraint b. Mitten restraints c. A mummy restraint d. Elbow restraints

19. A child had surgery on the face and needs to keep the hands away from the surgical site. Which restraint should the nurse use to accomplish this outcome?

ANS: D

The nurse applies bilateral elbow restraints (freedom splint) so the child cannot touch the operative area. They prevent elbow flexion. The child will still be able to hug the parent or hold onto objects. Mitten restraints are inadequate because the hands could still access the face. A mummy restraint is used for short-term examination of a child. Although it does confine, the mummy restraint is more like swaddling. The use of jacket restraints has been discouraged because of safety risks associated with their use and the child’s entire upper body does not need to be restrained.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Identification of the person at fault b. An appropriate consequence for the individual at fault c. Reason the event occurred d. A plan for the prevention of this event

20. The nurse participates in the investigation of an incident in the agency. As a result of the root cause analysis, what would the nurse expect as the ultimate outcome?

ANS: D

A plan for prevention of a similar event happening again is the ultimate outcome of this investigation. The investigation will determine all contributing factors in the occurrence of the event, with the goal of identifying methods to prevent those failures from recurring.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Ask the family about how patient communicates needs. b. Assess the patient with the Mini-Mental State Exam in the morning. c. Recommend the oncoming nurse request prn sedation medications. d. Move the patient to a room near the nurses’ station.

21. The nurse is giving report to the night 1900–0700 shift and describes a confused elderly patient who wanders. What action by the oncoming nurse is most appropriate?

ANS: A

Often patients wander due to an unmet need, such as hunger or needing to use the bathroom. The nurse should first ask the family if the patient “communicates” these needs by wandering. This will help the nurse plan the most individualized care. Cognitive assessments should be done at night or when cognitive status usually diminishes. Sedation medications are not indicated and can cause safety problems. It may or may not be possible to move the patient but a more wholistic approach considers the patient’s needs.

N

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Have the device inspected by the appropriate hospital department for safety. b. Have the patient take it home and use one from the hospital supply. c. Tell the patient that the personal machine cannot be used. d. Notify the provider to get permission for the patient to use the machine.

22. The nurse is caring for a patient who has brought in a personal CPAP device to use at night. What does the nurse need to do in addition to contacting respiratory therapy?

ANS: A

If a patient brings a device, it must be inspected for safe wiring and function before use through the process established by the agency. A patient should be able to use his or her own equipment such as CPAP since it is fitted for personal use. The provider cannot give permission without the safety inspection.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. The nurse’s supervisor b. Poison control center c. SDS sheets d. Employee health services

23. The nurse is caring for a patient and is exposed to a chemotherapy drug during IV administration. Where can the nurse obtain information about the drug that is necessary for an exposure-related incident?

ANS: C

Chemicals in medications (e.g., chemotherapy drugs), anesthetic gases, disinfectants, and cleaning solutions are potentially toxic. They injure the body after skin or mucous membrane contact, after ingestion, or when vapors are inhaled. Health care agencies provide employees access to Safety Data Sheets (SDSs, formerly called Material Data Safety Sheets or MSDS) for each hazardous chemical in the workplace. An SDS contains information about properties of the chemical (melting point, boiling point, flash point, etc.), toxicity, health effects, first aid, reactivity, safe handling, storage, disposal, protective equipment to use, and spill-handling procedure. The nurse’s supervisor, employee health services, or poison control center may also have the information, but they will go to the same place (the SDS sheets) to obtain that information.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Coordinates with the nursing staff so someone is always with the patient. b. Restrains the patient so prevent falling out of bed and medical device removal. c. Requests order to remove urinary catheter placed in the emergency department d. Places the patient on safety precautions and communicates this action.

24. A student is caring for a patient admitted with acute alcohol withdrawal. The patient is very agitated and flailing about in the bed. What action by the student requires the registered nurse to intervene?

ANS: B

Restraints are always used as a last resort, but in patients experiencing acute alcohol withdrawal, restraints are known to increase agitation. The other options are correct interventions.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Call for help. b. Suction the airway. c. Position patient supine. d. Hold arms securely.

25. A patient is having a seizure and has fallen to the floor. After placing a pillow under the patient’s head, what action does the nurse take next?

ANS: A

After cushioning the patient’s head, the nurse should call for help. The nurse may or may not need to suction the airway. The patient should be placed in a side-lying position if possible. Do not restrain limbs; if the patient is at risk for injury, move objects away from the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Inform social services about the noncompliant family. b. Teach the family the profound consequences of untreated seizures. c. Assess the family’s cultural values and norms related to seizures. d. Ask the family to leave during a seizure and treat the child then.

26. A nurse is caring for a child who has frequent seizures. The family does not want the seizures treated and appear to be in awe when they occur. What action by the nurse is best?

ANS: C

The nurse should always assess patients’ and families’ culture values, norms, and expectations. This family’s culture may place special significance on the seizures which is leading them to reject treatment. The nurse should teach the family but without the negative focus of “profound consequences”. Treating the child against the parents’ wishes (without a court order) is an ethical violation. It is too early to label the family as noncompliant.

DIF: Cognitive Level: Applying OBJ: NCLEX: Psychosocial Integrity

TOP: Nursing Process: Assessment a. Yelling for help b. Removing the patient from the room c. Pulling the fire alarm d. Calling security

27. After noticing a fire in a patient’s room, what action by the nurse takes priority?

ANS: B

The actions steps in case of a fire are RACE: Rescue those in danger, Activate the fire alarm, Confine the fire, and Extinguish the fire. The first would first remove anyone in that patient’s room.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Grabbing an ABC-type fire extinguisher b. Pulling the pin completely out of the extinguisher c. Aiming at the highest point of the flames d. Using the extinguisher in a sweeping motion

28. At a safety workshop nurses are being taught to use the fire extinguishers on common fires. What action by the nurse requires the teacher to review the material?

ANS: C

When using a fire extinguisher, aim at the base of the flames. The other actions are appropriate.

DIF: Cognitive Level: Evaluating OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Evaluation

Multiple Response

1. The nurse is caring for a patient who just received a diagnosis of a seizure disorder. What supplies should the nurse gather to have at the bedside? (Select all that apply.)

a. A suction device with catheters b. Extra pillows to pad the bed c. A padded tongue blade d. Oxygen source and nasal cannula e. Intubation equipment

ANS: A, D

A suction device with catheters and an oxygen source with nasal cannula will help maintain the airway should it become a problem. Extra pillows on the bed could cause suffocation during a seizure; firm padding on the sides of the bed are recommended instead. Padded tongue blades are no longer used in the care of patients with seizures. Intubation equipment is not routinely needed.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Planning a. Activate the fire alarm. b. Use a type ABC fire extinguisher. c. Rescue the patients from the unit. d. Put wet towels along the base of the doors. e. Use a type B fire extinguisher. f. Aim the nozzle at the top of the fire.

2. A nurse notes smoke coming from a garbage can in an otherwise empty nursing station. Which actions should the nurse take? (Select all that apply.)

ANS: A, B

Activate the fire alarm first; then use a type ABC fire extinguisher to put out the fire. An ABC type is the most commonly used extinguisher and will work on ordinary combustibles, liquids, and electrical fires. Aim the nozzle of the extinguisher at the base of the fire, not the top. The fire is just smoking; so there is no need to evacuate at this time. The patients are safer where they are since they are not in the area where the fire is smoldering. This small fire could be extinguished easily by the time wet towels are placed along the base of the doors.

N

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Frequent observation of patients b. Involving patients and families c. Frequent reorientation d. Four side rails e. Wraparound belt with quick release

3. Which of the following are examples of alternatives to restraint use in patient care? (Select all that apply.)

ANS: A, B, C, E

Modifications of the environment are effective alternatives to restraints. More frequent observation of patients, involvement of family caregivers during visitation, and frequent reorientation are also helpful measures. Having all four side rails up is considered a restraint. A wraparound lap belt that the patient can release is not a restraint.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Type b. Duration c. Purpose d. Location e. Size

4. The Joint Commission restricts the use of restraints to the least restrictive device necessary to prevent disruption of needed care. The order for restraints must include which of the following? (Select all that apply.)

ANS: A, B, C, D

Order must include purpose, type, location, and time or duration of restraint. Long-term care settings require informed consent from a family member prior to use. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours. Size is determined by the nurse’s judgment.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Hypoglycemia b. Hypoxia c. Alcohol abuse d. Electrolyte imbalances e. Emotional excitement

5. A nurse is assessing a patient after a seizure. What precipitating factors does the nurse consider as possibly causing the seizure? (Select all that apply.)

ANS: A, B, C, D

Emotional excitement is not a usual cause of seizures. All other options are possible causes of seizures the nurse would assess for.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

N

TOP: Nursing Process: Implementation a. Staring b. Rapid eye blinking c. Not responding d. Sudden fever e. Head nodding

6. The nurse is reminding the unlicensed assistive personnel about manifestations of a possible impending seizure. What manifestations does the nurse include? (Select all that apply.)

ANS: A, B, C, E

Staring, rapid eye blinking, brief periods of not responding, and head nodding are some signs of a possible pending seizure. Febrile seizures are common in children, but a sudden fever is not a manifestation of a pending seizure.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Safe and Effective Care Environment

TOP: Integrated Process: Teaching-Learning