A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

Observe the time of onset and end of seizure activity.

Remove objects within reach of the client's arms and legs.

Loosen any restrictive clothing around the neck.

Place a padded tongue blade in the client's mouth

Answer and Explanation

The Correct Answer is B

Choice A reason: Observing the time of onset and end of seizure activity is important, but it is not the priority action. The nurse should first ensure the safety of the client and prevent injury.

Choice B reason: Removing objects within reach of the client's arms and legs is the correct action, as it prevents the client from hitting or injuring themselves during the seizure. The nurse should also lower the bed and raise the side rails.

Choice C reason: Loosening any restrictive clothing around the neck is a good practice, but it is not as urgent as removing objects. The nurse can do this after ensuring the client's safety.

Choice D reason: Placing a padded tongue blade in the client's mouth is a wrong and dangerous action, as it can cause choking, aspiration, or damage to the teeth and oral mucosa. The nurse should never force anything into the client's mouth during a seizure.

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Correct Answer is A

Explanation

Choice A reason: Maintaining pressure to the puncture site and observing for drainage is the priority nursing intervention for a patient who had a lumbar puncture. It helps to prevent bleeding, hematoma, and cerebrospinal fluid leakage, which can cause complications such as infection, headache, or nerve damage.

Choice B reason: Completing a pain assessment and administering an ordered analgesic, as needed, is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause mild to moderate pain and discomfort at the puncture site, which can be relieved by analgesics, ice packs, or massage.

Choice C reason: Informing the patient they may feel pressure and sharp pain in their lower back for several hours is an important nursing intervention for a patient who had a lumbar puncture, but it is not the priority. Lumbar puncture can cause transient sensations of pressure and pain in the lower back, which can be reduced by lying flat, avoiding sudden movements, and drinking fluids.

Choice D reason: Assessing pulses distal to the lumbar puncture site every two hours is not an appropriate nursing intervention for a patient who had a lumbar puncture. Lumbar puncture does not affect the blood circulation to the lower extremities, unless there is a complication such as hematoma or nerve compression. Therefore, the nurse should monitor the neurological status, vital signs, and signs of infection or bleeding.

A. There is total absence of dopamine at receptors in brain cells controlling motor movement, causing Parkinson symptoms to appear. B. There is an excess of dopamine production and deficiency of acetylcholine production. C. There is a decreased production of dopamine and excess of acetylcholine. D. There is a deterioration of the myelin sheath of the basal ganglia and the person has tremors.

Correct Answer is C

Explanation

Choice A reason: There is total absence of dopamine at receptors in brain cells controlling motor movement, causing Parkinson symptoms to appear, is not the correct statement. Parkinson disease is not caused by a complete lack of dopamine, but by a gradual loss of dopamine-producing neurons in the substantia nigra, a part of the brain that regulates movement. The symptoms of Parkinson disease, such as tremor, rigidity, and bradykinesia, appear when about 80% of the dopamine neurons are lost.

Choice B reason: There is an excess of dopamine production and deficiency of acetylcholine production, is not the correct statement. Parkinson disease is not caused by an excess of dopamine, but by a deficiency of dopamine. Dopamine is a neurotransmitter that helps to control movement, balance, and coordination. Acetylcholine is another neurotransmitter that works in opposition to dopamine. When dopamine is low, acetylcholine becomes dominant and causes abnormal muscle movements.

Choice C reason: There is a decreased production of dopamine and excess of acetylcholine, is the correct statement. Parkinson disease is caused by a decreased production of dopamine and excess of acetylcholine. This creates an imbalance in the neurotransmitters that regulate movement, leading to the characteristic symptoms of Parkinson disease, such as tremor, rigidity, and bradykinesia.

Choice D reason: There is a deterioration of the myelin sheath of the basal ganglia and the person has tremors, is not the correct statement. Parkinson disease is not caused by a deterioration of the myelin sheath, but by a degeneration of the dopamine neurons. Myelin is a fatty substance that covers the axons of the nerve cells and helps to transmit electrical impulses. The basal ganglia are a group of structures in the brain that are involved in movement, learning, and emotion. Tremors are one of the symptoms of Parkinson disease, but they are not the only or the most specific one.

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A nurse is caring for a client who begins to exhibit seizure activity while in bed. Which of the following actions should the nurse implement to care for the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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Correct Answer is C

Explanation

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