The client has experienced an eclamptic seizure. Which of the following interventions by the nurse will help stabilize the client? (Select all that apply)
Explaining procedures.
Treating nausea.
Ensuring side rails are padded.
Assisting with breast pumping.
Evaluating blood pressure frequently.
Evaluating for headache.
Assessing deep tendon reflexes.
Minimizing visitors.
Correct Answer : C,E,G,H
Choice A rationale
Explaining procedures is important for patient understanding and consent, but it does not directly stabilize the client's condition during an eclamptic seizure.
Choice B rationale
Treating nausea can provide symptomatic relief but does not address the primary concerns of airway protection, seizure control, and hemodynamic stability in eclamptic patients.
Choice C rationale
Ensuring side rails are padded prevents injury during seizures by providing a protective barrier, reducing the risk of trauma from uncontrolled movements.
Choice D rationale
Assisting with breast pumping does not directly impact the stabilization of an eclamptic patient. The priority is managing seizures and ensuring patient safety.
Choice E rationale
Evaluating blood pressure frequently allows for early detection of hypertension or hypotension, guiding appropriate interventions to maintain hemodynamic stability and prevent complications.
Choice F rationale
Evaluating for headache is important for assessing potential complications of eclampsia, such as intracranial hypertension, but does not directly stabilize the patient during an acute seizure.
Choice G rationale
Assessing deep tendon reflexes helps monitor neurological status and the effectiveness of magnesium sulfate therapy, guiding further treatment decisions to prevent complications.
Choice H rationale
Minimizing visitors reduces environmental stimuli, which can help lower stress levels and prevent triggering additional seizures, contributing to the patient's stabilization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","F","G"]
Explanation
Choice B rationale
Proteinuria indicates preeclampsia, which involves increased glomerular permeability due to endothelial damage. Normal protein in urine is <150 mg/day.
Choice F rationale
Hyperreflexia can be a sign of CNS irritability in preeclampsia, which can lead to seizures if untreated. Normal reflexes are 2+.
Choice G rationale
Assessing lung sounds is critical as pulmonary edema can develop in severe preeclampsia due to increased capillary permeability. Normal breath sounds are clear and equal bilaterally.
Choice D rationale
A vision test helps assess for visual disturbances due to cerebral edema or optic nerve involvement in preeclampsia. Normal visual acuity is 20/20.
Choice A rationale
Hemoglobin assessment could indicate anemia, but it does not specifically address preeclampsia symptoms. Normal hemoglobin is 12-16 g/dL for women.
Choice C rationale
Perineal assessment checks for infection or hematoma but is less likely to explain systemic symptoms like headache and dizziness.
Choice E rationale
Skin turgor assesses hydration status, but dehydration is less likely to explain severe headache, dizziness, and visual disturbances. Normal skin turgor is immediate recoil.
Correct Answer is A
Explanation
Choice A rationale
Hydralazine decreases blood pressure by vasodilation, improving renal perfusion and function. Enhanced kidney function promotes diuresis, balancing fluid levels and reducing hypertension.
Choice B rationale
While controlling blood pressure indirectly benefits liver health, hydralazine's primary effect on vasodilation does not directly support liver function.
Choice C rationale
Hydralazine primarily lowers blood pressure through vasodilation. Preventing arrhythmias is more directly associated with medications affecting cardiac conduction rather than vasodilators.
Choice D rationale
Lowering cholesterol levels is not a direct effect of hydralazine. Its primary action is reducing blood pressure through vascular smooth muscle relaxation, decreasing hypertension.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.