Á nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Move objects away from the client."

"Place the client on his back."

"Insert a padded tongue blade into the client's mouth."

"Restrain the client."

Answer and Explanation

The Correct Answer is A

A. Moving objects away prevents injury during the seizure and is a critical safety measure.

B. Placing the client on their side, rather than on their back, helps maintain an open airway and prevents aspiration.

C. Inserting anything into the client's mouth, including a padded tongue blade, is not recommended as it may cause injury.

D. Restraining the client could result in injury and is not advised.

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Correct Answer is C

Explanation

A. Checking for fecal impaction can help relieve the cause of autonomic dysreflexia but should be done after positioning the client.

B. Skin breakdown can trigger autonomic dysreflexia, but the immediate priority is to lower blood pressure by sitting the client up.

C. Placing the client in a sitting position helps lower blood pressure, which is the immediate concern in autonomic dysreflexia.

D. Checking for bladder distention is essential to find the trigger, but positioning comes first to manage the acute blood pressure elevation.

A. "It increases their risk of experiencing a stroke." B. "It can increase their risk for falls." C. "It can increase their blood pressure." D. "It can increase their risk for infection."

Correct Answer is B

Explanation

A. While antipsychotics may slightly increase stroke risk in older adults, the primary concern for dementia clients is often fall risk.

B. Many sedative and antipsychotic medications increase the risk of falls, especially in older adults, due to their sedating effects and impact on balance.

C. These medications do not typically cause an increase in blood pressure; they may actually lower it, contributing to dizziness and fall risk.

D. Infection risk is not directly increased by these medications, although fall injuries can complicate recovery and care.

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Á nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is caring for an older adult client who has dementia. The client's family member asks why the provider will not prescribe a medication to calm the client down. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

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