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
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}

Rationale for correct choices

• Physical safety: During an active seizure, the immediate priority is protecting the client from injury. The nurse must ensure the environment is safe by removing nearby objects, lowering the client to the floor if necessary, and preventing head trauma. Attempting to control other aspects before ensuring safety can place the client at risk for fractures, head injury, or aspiration. Protecting the client from harm is always the first priority in seizure management.

• Positioning: After ensuring the client’s safety, positioning the client is essential to maintain airway patency and prevent aspiration. Placing the client on their side allows secretions or vomitus to drain from the mouth and helps keep the airway clear. Proper positioning also reduces the risk of aspiration pneumonia. Maintaining airway protection is the next critical step following environmental safety.

Rationale for incorrect choices

• Blood pressure: Monitoring blood pressure is important in overall assessment, but it is not the immediate priority during active seizure activity. The primary concerns are airway protection and prevention of injury. Vital signs can be assessed after the seizure subsides and the client is stabilized. Addressing blood pressure before safety and airway management would delay critical interventions.

• Privacy: Maintaining privacy is important for dignity and comfort but is not the immediate concern during a medical emergency such as an active seizure. Life-preserving interventions must take priority over privacy considerations. Immediate action focuses on preventing injury and maintaining airway.

• PRN medication: Lorazepam may be administered to control seizure activity, particularly if the seizure is prolonged. However, medication administration follows initial safety and airway interventions. Attempting to administer medication before ensuring the client is protected from injury and properly positioned may compromise safety. Stabilization and positioning occur first.

• Incontinence: Loss of bladder or bowel control can occur during seizures, but managing incontinence is not a priority during the event. The nurse should address hygiene and comfort after the seizure has ended and the client is stable. Immediate care focuses on safety, airway, and seizure control rather than cleanup.

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 C

Explanation

A. "I had a bowel movement, but I was able to save the urine.": This statement indicates a misunderstanding. Urine that is contaminated with fecal matter cannot be included in a 24-hour collection because it may alter the chemical and microscopic analysis. Proper technique requires discarding any urine contaminated with stool and resuming collection with the next void.

B. "I have a specimen in the bathroom from about 30 minutes ago.": Simply having a recent urine sample does not demonstrate understanding of the 24-hour collection process. The client must collect all urine over the entire 24-hour period, starting after the first void is discarded, to ensure accurate measurement of substances such as protein, creatinine, or hormones.

C. "I flushed what I urinated at 7:00 a.m. and have saved all urine since.": This statement demonstrates correct understanding of the procedure. The first morning void is discarded to mark the start of the 24-hour collection, and all subsequent urine is collected in the designated container. This ensures that the total volume represents a full 24-hour period for accurate analysis.

D. "I drink a lot, so I will fill up the bottle and complete the test quickly.": Rapidly filling the collection container by excessive fluid intake does not adhere to the 24-hour collection protocol. The collection must include all urine voided naturally over the 24-hourperiodregardless of fluid intake, to maintain accuracy in measuring the substances of interest.

A. Wrap blankets around all four sides of the bed. B. Apply restraints during seizure activity. C. Place the client in a supine position during seizure activity. D. Have a tongue depressor at the client's bedside.

Correct Answer is A

Explanation

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.

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 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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who requires a 24-hr urine collection. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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?

Correct Answer is A

Explanation

A nurse is caring for a client who is having difficulty breathing. The client is supine and is receiving supplemental oxygen via a nasal cannula. Which of the following interventions should the nurse take first?

A nurse is admitting a client who has rubella. Which of the following types of transmission-based precautions should the nurse initiate?

A nurse in an emergency department is caring for a client. Complete the following sentence by using the list of options. The nurse should first dropdown followed bydropdown.

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 planning an educational program for a group of older adults at a senior living center. Which of the following recommendations should the nurse include?

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?

A nurse is caring for a client with a diagnosis of terminal cancer. Which of the following statements by the client should indicate to the nurse that the client is ready to hear information regarding palliative care?

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 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
.