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.

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Correct Answer is B

Explanation

Choice A rationale:
Delivering meal trays to clients in their rooms is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.

Choice B rationale:
Observing postoperative clients who are confused requires a higher level of skill and knowledge than delivering meal trays. Volunteers are not typically trained to assess and monitor patients for changes in their condition, and they may not be able to recognize and respond to potential emergencies. This task is best assigned to a licensed nurse or other qualified healthcare professional.

Choice C rationale:
Assisting ambulatory clients with meals is another task that can be safely assigned to volunteers. This task involves helping patients with simple activities such as opening food containers and cutting food. Volunteers can be trained to perform these tasks safely and effectively.

Choice D rationale:
Delivering mail is a simple task that does not require any specialized skills or knowledge. Volunteers can be safely assigned this task, as it does not involve any direct patient care or decision-making.

A. Palpation of the patient's lymph nodes B. Auscultation of the patient's apical heart rate C. Palpation of the patient's liver D. Percussion of the patient's abdomen

Correct Answer is A

Explanation

Choice A rationale:
Lymph nodes are small, bean-shaped structures that play a crucial role in the immune system. They filter lymph fluid, which carries white blood cells and other immune cells throughout the body.
When the body is fighting an infection or other immune challenge, lymph nodes often swell and become tender. This is because they are actively working to filter out pathogens and activate immune cells.
Palpation of the lymph nodes can provide valuable information about the patient's immune function. The nurse can assess for enlargement, tenderness, and mobility of the lymph nodes.
Lymph node assessment is a non-invasive, painless procedure that can be performed quickly and easily.
Choice B rationale:
Auscultation of the apical heart rate is important for assessing cardiovascular function, but it does not directly assess immune function.
While heart rate can be indirectly affected by certain immune conditions (e.g., fever), it is not a primary indicator of immune system activity.
Choice C rationale:
Palpation of the liver can provide information about liver size and consistency, but it does not directly assess immune function.
The liver plays a role in immune function by producing proteins that help fight infection, but its size and consistency do not necessarily reflect its immune activity.
Choice D rationale:
Percussion of the abdomen can be used to assess the size and location of abdominal organs, but it does not directly assess immune function.
While certain immune conditions may involve abdominal organs (e.g., splenomegaly), percussion is not a primary method for assessing immune function.

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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

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Explanation

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Correct Answer is A

Explanation

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