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: This is correct. Monitoring of neurologic status is a priority intervention for a patient with bacterial meningitis, as the infection can cause inflammation and damage to the brain and spinal cord. The nurse should assess the patient's level of consciousness, pupillary response, cranial nerve function, and signs of increased intracranial pressure.

Choice B reason: This is incorrect. Infusion of large volumes of isotonic intravenous fluids is not indicated for a patient with bacterial meningitis, as it can worsen the cerebral edema and increase the intracranial pressure. The patient should receive adequate hydration, but not excessive fluids.

Choice C reason: This is incorrect. Standard precautions are not sufficient for a patient with bacterial meningitis, as the infection can be transmitted through respiratory droplets. The patient should be placed on droplet precautions, which include wearing a mask, gloves, and gown, and limiting the contact with other patients and visitors.

Choice D reason: This is incorrect. Distraction activities to reduce long periods of sleep are not appropriate for a patient with bacterial meningitis, as the patient may need rest and sedation to reduce the agitation and pain. The nurse should provide a quiet and dark environment, and avoid unnecessary stimuli that can increase the intracranial pressure.

A. Apples and grapes. B. Popsicles, gelatin, or juice. C. Beans. D. Cheese.

Correct Answer is B

Explanation

Choice A (Apples and grapes): While fruits like apples and grapes are generally healthy options, they may not be the best choice for a client in sickle cell crisis. These fruits are high in fiber and may require a significant amount of chewing, which can be challenging for someone experiencing a sickle cell crisis.

Choice B (Popsicles, gelatin, or juice): This choice is the most suitable for a client in sickle cell crisis. During a crisis, it's important to stay hydrated, and these options provide hydration along with easily digestible carbohydrates, which can be beneficial for maintaining energy levels.

Choice C (Beans): While beans are a good source of protein and fiber, they may not be well tolerated during a sickle cell crisis due to their high fiber content.

Choice D (Cheese): Although cheese is a source of protein and calcium, it may not be the best option during a sickle cell crisis, as dairy products can be harder to digest and may not contribute to hydration.

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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

The nurse is caring for a patient with bacterial meningitis caused by Haemophilus influenzae type B. What should the nurse include in the patient's plan of care?

Correct Answer is A

Explanation

Which of the following foods would the nurse encourage the client in sickle cell crisis to eat?

Correct Answer is B

Explanation

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