The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Loosen the patient's clothing

Ease the patient to the floor if standing

Restrain the patient

Protect the patient's mouth with a padded tongue blade

Provide privacy

Answer and Explanation

Correct Answer : A,B,E

Choice A rationale:
Loosening the patient's clothing around the neck and chest promotes easier breathing during the seizure. It also prevents potential injury from constrictive clothing that could restrict movement or circulation.
Choice B rationale:
Easing the patient to the floor if they are standing helps to prevent falls and injuries that could occur due to loss of consciousness and muscle control during the seizure. It's crucial to guide the patient gently to the floor to avoid abrupt movements that could trigger or worsen the seizure.
Choice C rationale:
Restraining the patient during a seizure is not recommended as it can cause harm. Attempting to restrain a patient's movements during a seizure can lead to muscle strains, joint injuries, or even fractures. It can also increase anxiety and agitation, potentially prolonging the seizure.
Choice D rationale:
Protecting the patient's mouth with a padded tongue blade is not necessary and can even be dangerous. It was once a common practice, but it's now discouraged as it can cause oral injuries, obstruct the airway, or induce vomiting.

Choice E rationale:
Providing privacy helps to protect the patient's dignity and reduce any potential embarrassment during the seizure. It also creates a calmer and less stimulating environment, which can be beneficial in managing the seizure.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:
Coughing and deep breathing are essential for mobilizing and removing secretions from the airways, which is crucial for improving airway clearance in patients with pneumonia. These techniques help to loosen mucus and bring it up from the lungs, allowing it to be expelled through coughing.
Hydration maintenance is also critical because it helps to thin secretions, making them easier to cough up. Adequate hydration helps to keep mucus moist and less sticky, which promotes easier expectoration.
Choice B rationale:
Keeping the head of the bed elevated can help to improve oxygenation and reduce the work of breathing, but it does not directly address the issue of airway clearance. It may be a helpful adjunct intervention, but it's not the priority for this specific nursing diagnosis.
Choice C rationale:
Preparation for insertion of a tracheostomy tube is a more invasive intervention that may be necessary in severe cases of airway obstruction, but it is not the first-line intervention for ineffective airway clearance related to pneumonia. It would be considered if other measures fail to maintain adequate ventilation.

Choice D rationale:
Providing supplemental oxygen can help to improve oxygenation in patients with pneumonia, but it does not directly address the issue of airway clearance. It's important to support oxygenation, but it's not the primary intervention to clear secretions.

A. Administer the medication B. Determine the location of the pain C. Reposition the client D. Review the effects of the pain medication

Correct Answer is B

Explanation

Choice A rationale:
Administering the medication without first assessing the pain could lead to inappropriate medication administration and potentially mask underlying issues. It's crucial to gather more information about the pain before providing any medication.

Choice C rationale:
While repositioning might offer some relief in certain cases, it's not the first step in pain management. A thorough assessment to understand the nature, location, and severity of the pain is essential for determining the most appropriate intervention.

Choice D rationale:
Reviewing the effects of previous pain medication is important, but it doesn't take priority over assessing the current pain. Understanding the current pain experience is necessary to make informed decisions about medication administration and other interventions.
Choice B rationale:

Determining the location of the pain is the crucial first step in pain assessment. It helps to: Identify the potential source of the pain, which can guide treatment choices.
Understand the pain's characteristics, such as its quality, intensity, and duration.
Evaluate for any associated symptoms or patterns, which can provide further insights into the underlying cause. Assess for any aggravating or alleviating factors, which can help tailor treatment strategies.
Monitor the effectiveness of interventions by comparing changes in pain location and characteristics.

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

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What intervention should the nurse identify as a priority for a client with a nursing diagnosis of ineffective airway clearance related to HIV related pneumonia?

Correct Answer is A

Explanation

A nurse is caring for a client who requests prescription pain medication. Which of the following actions should the nurse perform first?

Correct Answer is B

Explanation

A nurse is teaching a client who has a new prescription for colchicine to treat gout. Which of the following instructions should the nurse include?

A nurse is caring for a client who is taking naproxen following an exacerbation of rheumatoid arthritis. Which of the following statements by the client requires further discussion by the nurse?

A nurse is providing teaching to a client who has a new diagnosis of fibromyalgia. Which of the following client statements indicates an understanding of the teaching?

The nurse is planning education for a patient diagnosed with fibromyalgia. Which risk factors should the nurse include in the teaching plan? (Select all that apply)

A nurse is caring for a patient with rheumatoid arthritis. The patient is prescribed hydroxychloroquine to slow the progression of the disease. Which of the following laboratory results should the nurse monitor for this patient?

A nurse is performing discharge teaching for a client who has seizures and a new prescription for phenytoin. Which of the following statements by the client indicates a need for further teaching?

The client tells the nurse, "I am about to have a seizure." Which of the actions should the nurse implement? (Select all that apply)