A nurse is reinforcing discharge teaching to a client who has epilepsy. Which of the following instructions should be included in the teaching?
Placing padding around or under the patient's head
Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
Have the necessary equipment and/or personnel in case the patient doesn't spontaneously breath when the seizure is over
Insert a tongue depressor in the patient's mouth
Note the time the seizure started
Hold the patient down to prevent injury
Correct Answer : A,B,C,E
A. Placing padding around or under the patient's head
This is a helpful instruction to include. Placing padding around or under the patient's head can help prevent injury during a seizure by cushioning the head against impact with the ground.
B. Positioning the patient on the side once the relaxation stage is entered to allow oral secretions to drain
This is a correct instruction. Positioning the patient on their side (recovery position) can help prevent aspiration if vomiting occurs during or after the seizure. It also helps clear oral secretions and maintain a clear airway.
C. Having the necessary equipment and/or personnel in case the patient doesn't spontaneously breathe when the seizure is over
This is an important instruction. It is crucial to have emergency equipment (such as oxygen and suction) readily available and to be prepared to provide respiratory support if the patient does not spontaneously breathe after the seizure.
D. Inserting a tongue depressor in the patient's mouth
This is an incorrect instruction. It is not recommended to insert anything into the patient's mouth during a seizure as it can cause injury to the teeth, gums, or airway. Additionally, it is a common misconception that tongue swallowing occurs during seizures, which is rare.
E. Noting the time the seizure started
This is a critical instruction. Noting the time the seizure started helps healthcare providers assess the duration of the seizure and determine if medical intervention is necessary. It also helps monitor the patient's recovery and response to treatment.
F. Holding the patient down to prevent injury
This is an incorrect instruction. Holding the patient down during a seizure can cause injury to both the patient and the person restraining them. It is important to create a safe environment by removing hazards and guiding the patient away from dangerous objects or situations, but holding them down is not appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. B6 (Pyridoxine):
Vitamin B6, also known as pyridoxine, is known to reduce the therapeutic effects of levodopa. It competes with levodopa for absorption in the gastrointestinal tract and can decrease the amount of levodopa that reaches the brain, thereby diminishing its effectiveness in treating Parkinson's disease symptoms.
B. A (Retinol):
Vitamin A, also known as retinol, is not typically associated with reducing the therapeutic effects of levodopa. Vitamin A plays important roles in vision, immune function, and cellular communication, but it does not interact with levodopa in a way that affects its therapeutic efficacy.
C. E (Alpha-Tocopherol):
Vitamin E, also known as alpha-tocopherol, is an antioxidant that plays a role in protecting cells from oxidative damage. While vitamin E supplementation is sometimes used in Parkinson's disease management for its potential neuroprotective effects, it is not known to reduce the therapeutic effects of levodopa.
D. K (Phylloquinone):
Vitamin K, also known as phylloquinone, is primarily involved in blood clotting and bone metabolism. It does not interact with levodopa in a way that reduces its therapeutic effects.
E. C (Ascorbic Acid):
Vitamin C, also known as ascorbic acid, is not known to reduce the therapeutic effects of levodopa. While vitamin C has various roles in the body, including antioxidant activity and immune function support, it does not interfere with levodopa absorption or efficacy.
Correct Answer is A
Explanation
A. Toes turning up and spreading:
This description corresponds to the abnormal finding in the Babinski reflex. In a positive Babinski sign, the big toe (hallux) dorsiflexes (turns upward) and the other toes fan out. This response is abnormal in adults but normal in infants up to a certain age.
B. Downward curl of the toes:
This response is typical of the normal plantar reflex, where the toes curl downward (plantar flexion) in response to stimulation of the sole of the foot. It is not indicative of the Babinski reflex.
C. Pain in the big toe:
Pain in the big toe is not a characteristic finding of the Babinski reflex. The Babinski sign is assessed by observing the movement pattern of the toes in response to stimulation, rather than eliciting pain.
D. Big toe bending upward:
The big toe bending upward, or dorsiflexion of the big toe, is a specific component of the positive Babinski sign. However, it is typically accompanied by spreading of the other toes, which is the hallmark feature of the Babinski reflex.
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