A client with a history of seizures is being admitted to the emergency room after experiencing a partial seizure. Which question would be most appropriate for the nurse to ask the client?
“Were you feeling jittery or irritable prior to the seizure?”
“Are you feeling sleepy or very tired at this time?”
“When did you last take your seizure medication?”
“Do you know if you lost consciousness during the seizure?”
The Correct Answer is C
Choice A rationale:
While inquiring about pre-seizure symptoms can be informative, it's not the most crucial question at this point. The priority is to gather information about medication adherence to assess potential causes for the breakthrough seizure.
Choice B rationale:
Assessing for post-ictal fatigue is important, but it's not the most pressing question in the immediate aftermath of a seizure. Determining medication adherence takes precedence.
Choice D rationale:
Establishing whether consciousness was lost can aid in classifying seizure type, but it's not as critical as understanding medication adherence in the initial assessment.
Choice C rationale:
This question directly addresses a potential cause of the seizure. Understanding when the client last took their medication can help determine if missed or delayed doses contributed to the seizure, guide medication adjustments, and inform further seizure prevention strategies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Fever is the most reliable early indicator of infection in a client with low WBC because it is a direct physiologic response to the presence of pathogens. When the body detects an infection, it releases pyrogens, which act on the hypothalamus to raise the body's temperature. This elevated temperature helps to create an environment that is less hospitable to bacteria and viruses, and it also stimulates the immune system to fight the infection.
In clients with low WBC, the immune system is already compromised, so the fever response may be even more pronounced. It's important to note that even a slight elevation in temperature (as low as 100.4°F or 38°C) can be significant in these clients.
Choice B rationale:
Chills can also be a sign of infection, but they are not as specific as fever. Chills can occur for other reasons, such as exposure to cold or anxiety.
Choice C rationale:
Tachycardia, or increased heart rate, can also be a sign of infection, but it is not as reliable as fever. Tachycardia can occur for other reasons, such as dehydration, pain, or anxiety.
Choice D rationale:
Dyspnea, or shortness of breath, is not a typical early sign of infection. It is more likely to occur in later stages of infection, when the infection has spread to the lungs.
Correct Answer is A
Explanation
Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.
Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today