A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?

A sensory warning that a seizure is imminent

A brief loss of consciousness accompanied by staring

A continuous seizure state in which seizures occur in rapid succession

A period of sleepiness following the seizure during which arousal is difficult

Answer and Explanation

The Correct Answer is A

a. A sensory warning that a seizure is imminent: An aura is a subjective sensation or warning that a seizure is about to occur. It can manifest as visual, auditory, or other sensory experiences.

b. A brief loss of consciousness accompanied by staring: This describes an absence seizure, not an aura. Absence seizures are characterized by a brief loss of consciousness without convulsions.

c. A continuous seizure state in which seizures occur in rapid succession: This describes status epilepticus, not an aura. Status epilepticus is a medical emergency characterized by prolonged or rapidly recurring seizures.

d. A period of sleepiness following the seizure during which arousal is difficult: This describes the postictal state, not an aura. The postictal state is a period of altered consciousness or

sleepiness that may follow a seizure.

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Correct Answer is A

Explanation

a. Provide humidified oxygen: Humidification helps prevent the drying of mucous membranes, making secretions more manageable and less tenacious. This is an acceptable method to thin

secretions in a client with a tracheostomy.

b. Prelubricate the suction catheter tip with sterile saline when suctioning the airway: While lubrication with sterile saline is a common practice during suctioning to reduce trauma to the airway, it does not directly address the tenacity of secretions.

c. Perform chest physiotherapy prior to suctioning: Chest physiotherapy is a technique used to mobilize respiratory secretions, but it may not directly address the tenacity of secretions.

d. Hyperventilate the client with 100% oxygen before suctioning the airway: Hyperventilation with 100% oxygen is not a routine practice and may lead to respiratory alkalosis. Providing

humidified oxygen is a more appropriate approach.

A. Decrease the IV fluid infusion rate and limit oral fluid intake. B. Collect a urine specimen for culture and sensitivity. C. Continue routine care because the results are within the expected reference range. D. Evaluate urine output for amount and urine for specific gravity.

Correct Answer is D

Explanation

a. Decrease the IV fluid infusion rate and limit oral fluid intake: The client's BUN and creatinine levels are not significantly elevated, and limiting fluid intake may exacerbate dehydration.

Decreasing the IV fluid rate may not be indicated without further assessment.

b. Collect a urine specimen for culture and sensitivity: While obtaining a urine specimen is

important, the priority in this case is to evaluate the urine output for amount and specific gravity to assess renal function and fluid balance.

c. Continue routine care because the results are within the expected reference range: The elevated BUN, along with nausea and vomiting, suggests the need for further assessment rather than

continuing routine care without adjustments.

d. Evaluate urine output for amount and urine for specific gravity: This is the correct action to assess renal function and fluid balance. Monitoring urine output and specific gravity will help determine if the client's kidneys are effectively concentrating urine and adequately excreting waste products.

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A nurse is caring for a client who has a seizure disorder and reports experiencing an aura. The nurse should recognize the client is experiencing which of the following conditions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative following a tracheostomy and has copious and tenacious secretions. Which of the following is an acceptable method for the nurse to use to thin this client's secretions?

Correct Answer is A

Explanation

A nurse is caring for a male client who reports nausea and vomiting and is receiving IV fluid therapy. The client's BUN is 32 mg/dL, creatinine 1.1 mg/dL, and hematocrit 50%. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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