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:Swaying during a Romberg test indicates a positive result, suggesting proprioceptive deficits or sensory ataxia.

Choice B reason:Unequal pupil response to light relates to cranial nerve function, not balance assessed by the Romberg test.

Choice C reason: This is incorrect. Patient taking two attempts to touch their nose while their eyes are closed is a mild impairment of coordination, which may be due to neurologic changes or other factors such as fatigue or medication. This is not a significant finding that requires immediate attention.

Choice D reason: This is incorrect. Patient complaining of mild dizziness is a common symptom of neurologic changes or vestibular dysfunction. It is not a serious finding that requires immediate attention. The nurse should monitor the patient and provide comfort measures.

A. Presence of a synthetic silicone mesh stent in a coronary artery. B. Allergy to shellfish and iodine. C. Contact lenses. D. Presence of an internal insulin pump in the abdomen.

Correct Answer is D

Explanation

Choice A reason: Presence of a synthetic silicone mesh stent in a coronary artery is not a contraindication for MRI. Silicone is a non-magnetic material that does not interfere with the magnetic field or cause any harm to the patient or the device.

Choice B reason: Allergy to shellfish and iodine is not a contraindication for MRI. Shellfish and iodine are not related to the contrast agent used for MRI, which is usually gadolinium. However, the patient should inform the provider if they have any history of allergic reactions to contrast agents or any other medications.

Choice C reason: Contact lenses are not a contraindication for MRI. Contact lenses are made of plastic or silicone, which are non-magnetic materials that do not interfere with the magnetic field or cause any harm to the patient or the device. However, the patient should remove them before the procedure to avoid any discomfort or irritation.

Choice D reason: Presence of an internal insulin pump in the abdomen is a contraindication for MRI. Insulin pumps are electronic devices that contain metal parts, batteries, and wires, which can be affected by the magnetic field and cause malfunction, damage, or injury to the patient or the device. Therefore, the patient should inform the provider and the MRI technician about the insulin pump and follow their instructions on how to manage it before, during, and after the procedure.

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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 D

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