Which of the following manifestation should the nurse APPROPRIATELY observe during generalized seizures?

Correct Answer: A

Rationale: Generalized seizures involve both hemispheres of the brain and can present with various manifestations. The typical features of generalized seizures include loss of consciousness, dilated pupils, and muscular stiffening. These seizures may also involve other symptoms such as tonic-clonic movements, convulsions, and postictal confusion. Jerking movements of all extremities (option B) are more characteristic of tonic-clonic seizures, a subtype of generalized seizures. Facial grimace with patting and smacking (option C) may be seen in focal seizures originating from a certain area of the brain. A vacant stare with a brief loss of consciousness (option D) is more typical of absence seizures rather than generalized seizures.

Correct Answer: D

Rationale: The first step Nurse Gabriela should do when handling vaccines is to check the vial for the expiration date. It is crucial to ensure that the vaccine has not expired before proceeding with any further steps. Administering an expired vaccine can be ineffective or even harmful to the patient. Therefore, checking the expiration date is the foundational step in the safe and proper administration of vaccines.

Correct Answer: D

Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.

Correct Answer: A

Rationale: An occiput posterior fetal position, where the baby's head is facing the mother's abdomen rather than her back, can lead to prolonged and severe back pain during labor. This position can cause irregular contractions and difficulty in descending through the birth canal, resulting in abnormal labor progress. The back pain experienced in this case is often intense due to the pressure exerted on the mother's lower back and may also be associated with intense back labor. It is essential for the nurse to recognize this potential issue and assist in maneuvers or positions to help the baby rotate to a more optimal position for delivery.

Correct Answer: B

Rationale: When a nurse is delegating tasks to a nursing assistant, the principle that should guide the nurse's delegation decisions is assigning tasks based on the assistant's level of experience (Option B). It is essential to take into consideration the skills, competencies, and experience level of the nursing assistant to ensure that the tasks delegated are suitable for them to perform safely and effectively. Delegating tasks beyond the assistant's level of experience may result in errors, inefficiencies, or compromised patient care. Therefore, matching tasks with the assistant's experience level is crucial in successful delegation and providing quality patient care.

Correct Answer: C

Rationale: Introducing solid food to a three-month-old baby is considered a poor healthcare attitude as it goes against the recommended guidelines for infant feeding. The World Health Organization (WHO) and other health authorities suggest exclusive breastfeeding for the first six months of a baby's life, followed by the introduction of safe and appropriate complementary foods. Introducing solid food too early can increase the risk of food allergies, obesity, and other health issues in babies. Therefore, a young mother introducing solid food to her three-month-old baby is evidence of a poor family coping index related to healthcare attitudes.

Correct Answer: A

Rationale: Naloxone is a medication used to reverse the effects of an opioid overdose by binding to opioid receptors and displacing the opioids. Administering naloxone intravenously is the recommended intervention for managing a patient with a suspected opioid overdose as it can quickly reverse respiratory depression, sedation, and other effects of opioids. This intervention can be life-saving in cases of opioid overdose and is a critical step in the management of such patients. Providing respiratory support with bag-valve-mask ventilation may be necessary in addition to naloxone administration to ensure adequate oxygenation, but naloxone remains the primary intervention to reverse the effects of opioids. Encouraging the patient to drink fluids rapidly or administering benzodiazepines for sedation are not recommended interventions for managing a suspected opioid overdose.

Correct Answer: D

Rationale: A delimitation in a research study refers to setting specific boundaries or restrictions on the scope of the study. In this scenario, Gloria's decision to include only nurses with a minimum of three years experience as psychiatric nurses is a delimitation because it sets a specific criterion or boundary for the selection of participants. This helps to focus the study on a particular group of individuals who possess the required experience, ensuring the research is targeted and relevant to the topic being investigated.

Correct Answer: A

Rationale: Pressure injuries on the heels are a concern as they can develop quickly and lead to serious complications, especially in surgical patients who are immobile for extended periods. Applying pressure-relieving devices, such as heel protectors or foam dressings, can help alleviate the pressure on the affected areas and prevent further damage. These devices are designed to distribute pressure evenly and reduce the risk of pressure injuries. It is important for the nurse to address the issue promptly to prevent additional harm to the patient's skin integrity.