A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Wrap blankets around all four sides of the bed.

Apply restraints during seizure activity.

Place the client in a supine position during seizure activity.

Have a tongue depressor at the client's bedside.

Answer and Explanation

The Correct Answer is A

A. Wrap blankets around all four sides of the bed: Protecting the client from injury is the primary goal during seizure precautions. Padding the bed rails with blankets or seizure pads helps prevent trauma to the head and extremities during tonic-clonic movements. This reduces the risk of injury without restricting the client’s movement and is a standard safety measure.

B. Apply restraints during seizure activity: Restraining a client during a seizure can cause significant injury, including musculoskeletal damage or impaired breathing. During tonic-clonic seizures, the client’s movements are involuntary, and applying restraints may increase the risk of fractures or soft tissue injury.

C. Place the client in a supine position during seizure activity: Placing a client flat on their back increases the risk of airway obstruction and aspiration of saliva or vomitus during a seizure. The recommended position is side-lying (lateral) if possible, which promotes drainage of secretions and helps maintain a clear airway. Maintaining airway safety is a key priority during seizures.

D. Have a tongue depressor at the client's bedside: Inserting objects such as a tongue depressor or any device into the client’s mouth during a seizure is contraindicated. This practice can lead to broken teeth, airway obstruction, or injury to the oral cavity. Modern seizure management emphasizes protecting the client from injury and maintaining airway safety.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Hypotension: Hypotension is more commonly associated with fluid volume deficit rather than fluid overload. When intravascular volume is low, cardiac output decreases, resulting in reduced blood pressure. In fluid volume excess, the circulating blood volume increases, which typically leads to elevated blood pressure due to increased preload and vascular pressure.

B. Weak, thready pulse: A weak, thready pulse usually occurs in hypovolemia, where there is insufficient circulating blood volume to maintain adequate perfusion. In fluid volume excess, the pulse is more likely to be bounding due to increased stroke volume and elevated intravascular pressure, reflecting increased cardiac workload.

C. Slow capillary refill: Delayed capillary refill indicates poor peripheral perfusion, often seen in dehydration, shock, or fluid volume deficit. In fluid volume excess, circulation is generally adequate or increased, and capillary refill is not typically delayed unless severe cardiac dysfunction or circulatory compromise develops.

D. Distended neck veins: Jugular venous distention (JVD) occurs when increased intravascular volume causes elevated central venous pressure. This leads to visible engorgement of the neck veins. JVD is a classic clinical sign of fluid overload and may also be accompanied by edema, hypertension, and pulmonary congestion.

A. Neurological assessment B. Incisional drainage C. Urinary output D. Reported pain level E. Gastrointestinal assessment F. Vital signs

Correct Answer is ["C","D","F"]

Explanation

Rationale for correct choices

• Urinary output: The client produced only 15 mL of urine between 1100 and 1200 and none afterward, which indicates significantly decreased urine output. Postoperative urine output should generally remain at least about 30 mL/hr in adults to reflect adequate renal perfusion and circulating volume. Oliguria may signal hypovolemia, early shock, or decreased kidney perfusion after surgery. This finding requires prompt provider notification for further evaluation

• Reported pain level: The client reports worsening pain from 6/10 to 8/10 even after receiving IV morphine. Increasing pain despite analgesic administration can indicate complications such as internal bleeding, inadequate pain control, or surgical complications. Severe uncontrolled pain also increases sympathetic stimulation, which may contribute to tachycardia and physiologic stress.

• Vital signs: The client’s heart rate increased from 76/min to 116/min while blood pressure slightly decreased. Tachycardia in the postoperative period may indicate pain, hypovolemia, bleeding, or other complications. When combined with decreased urine output and worsening pain, the vital sign changes raise concern for possible postoperative complications such as fluid deficit or hemorrhage. These changes require prompt provider review.

Rationale for incorrect choices

• Neurological assessment: The neurological findings indicate that the client is drowsy but easily arousable and oriented to person, place, and time. The client can move all extremities and shows no evidence of neurological decline. Mild drowsiness is expected after anesthesia and opioid administration. These findings do not suggest an immediate complication requiring provider notification.

• Incisional drainage: The abdominal dressing had drainage that was marked at admission, and no additional drainage was noted afterward. Monitoring surgical drainage is important, but stable drainage without progression suggests the incision site remains unchanged. There is no indication of excessive bleeding, rapid saturation of the dressing, or new drainage. Therefore, this finding does not require immediate reporting.

• Gastrointestinal assessment: Hypoactive bowel sounds are a common and expected finding in the immediate postoperative period due to anesthesia and reduced gastrointestinal motility. The client initially experienced nausea but reported relief after receiving metoclopramide. These findings are consistent with normal postoperative recovery.

View Question and Answer

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

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?

Correct Answer is D

Explanation

Correct Answer is ["C","D","F"]

Explanation

A nurse is admitting a client. The nurse is reviewing the client's medical record. Which of the following actions should the nurse take? Select all that apply.

A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse implement for this client?

A nurse in a provider's clinic is caring for a client who has diarrhea The nurse is providing teaching for the client who has diarrhea. Select the 4 instructions that the nurse should include in the teaching.

A nurse is admitting a client who has an abdominal wound with a large amount of purulent drainage. Which of the following types of transmission precautions should the nurse initiate?

A nurse in the emergency department (ED) is caring for a client. Click to highlight the findings that indicate the client is malnourished. To deselect a finding, click on the finding again.

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client?

A nurse is caring for a client who has a new diagnosis of seizure disorder. Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown.

A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?